Aperion Care Tolleston Park

Inspectors wroteBased on record review and interview, the facility failed to prevent an avoidable pressure ulcer for an at-risk dependent resident resulting in the resident developing a facility-acquired stage four (full thickness of the skin) pressure ulcer with infection to the buttocks one month after admission to the facility. (Resident B)The immediate jeopardy began on 5/26/26, when the nursing staff found a malodorous stage four pressure ulcer to the buttocks which tested positive for infection when cultured. The Administrator, RN Corporate Wound Specialist, RN Consultant, Corporate Minimum Data Set (MDS) Nurse, and Director of Nursing (DON) were notified of the immediate jeopardy on 6/10/26 at 3:06 p.m. The immediate jeopardy was removed and the deficient practice corrected on 6/9/26, prior to the start of the survey, and was therefore Past Noncompliance.

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 shaving, nail care, providing showers, and incontinence care for 6 of 11 residents reviewed for ADLs. (Residents H, E, G, D, F, B)

Inspectors wroteBased on record review and interview, the facility failed to ensure a skin assessment was completed following an angiogram for 1 of 1 resident reviewed for change in condition and medications were administered as ordered for 3 of 5 residents reviewed for unnecessary medications. (Residents G, 24, 72, and 96)

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty and discolored floor tiles, marred walls and door frames, dusty ceiling vents, and dead insects in light fixtures for 2 of 3 units observed. (South and PCU)

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain a resident's dignity related to wearing a hospital gown during the day for 1 of 3 residents reviewed for dignity. (Resident 35)

Inspectors wroteBased on record review and interview, the facility failed to ensure evidence was provided related to Level 1 and Level 2 PASARR (Pre admission Screening and Annual Resident Review) screening for 1 of 1 resident reviewed for PASARR. (Resident 2)

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was in place for pain for a resident receiving opioid (narcotic pain medication) medication for 1 of 31 residents whose care plans were reviewed. (Resident 131)

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan conference was held quarterly for 1 of 1 resident reviewed for care planning. (Resident 1)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities to support the psychosocial well-being of cognitively impaired, dependent residents for 1 of 2 residents reviewed for activities. (Resident 8)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate documentation of pressure ulcers was completed upon admission for 2 of 3 residents reviewed for pressure ulcers. (Residents 2 and 133)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were provided with adequate supervision to prevent falls and accident hazards were not present in resident rooms for 2 of 3 residents reviewed for accidents. (Residents B and C)

Inspectors wroteBased on record review and interview, the facility failed to ensure acceptable parameters of nutrition were maintained related to obtaining a re-weight in a timely manner following a hospitalization for 1 of 4 residents reviewed for nutrition. (Resident H)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents with a gastrostomy tube (g-tube, the surgical insertion of a feeding tube) received the appropriate treatment related to administration of the tube feeding for 2 of 2 residents reviewed for tube feedings. (Residents 50 and 133)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were not left unattended on top of the medication cart during medication administration for 2 of 6 residents observed during medication pass. (Residents 7 and 46)

Inspectors wroteBased on record review and interview, the facility failed to ensure a medical record was complete and accurately documented related to a resident death for 1 of 5 residents reviewed for accidents. (Resident J)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to the storage of urinals and wash basins on 1 of 3 units. (The South Unit) The facility also failed to ensure a catheter port was cleansed prior to administering intravenous (IV) antibiotics for 1 of 1 resident observed for IV medication administration. (Resident 7)

Inspectors wroteBased on record review and interview, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to showers not being completed and documented for 2 of 3 residents reviewed for ADLs. (Residents B and D)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received necessary care and services, related to 72 hour assessments and neurological assessments not completed for a resident with an unwitnessed fall and medication not given as ordered for 1 of 3 residents reviewed for accidents and 1 of 3 residents reviewed for medication administration. (Residents C and G)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to treatments not completed as ordered by the Physician for 1 of 3 residents reviewed for pressure ulcers. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (Housekeeper 1) when cleaning a room where a COVID-19 positive resident resided (Resident F) and was in COVID-19 Transmission-Based Precautions, for one random observation for infection control.

Inspectors wroteBased on record review and interview, the facility failed to complete adequate fall follow up related to missing neurological assessments for 1 of 3 residents reviewed for falls. (Resident B)

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty and discolored floor tiles, marred walls, dirty and missing baseboards, broken mini blinds, dirty and rusty toilet bolts, missing toilet bolt covers, and caulk missing around the toilet for 3 of 3 units observed. (North, South and PCU)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's privacy was maintained related to staff not knocking on the door prior to entering the resident's room for 2 of 2 residents reviewed for privacy. (Residents 2 and 9)

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 dirty and long fingernails and the removal of facial hair for 3 of 10 residents reviewed for ADLs. (Residents 35, 58, and 236)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure non-pressure ulcer treatments were completed as ordered for 3 of 4 residents reviewed for skin conditions and failed to obtain a psychiatric consult as ordered for 1 of 5 residents reviewed for unnecessary medications. (Residents 94 and 107)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a palm protector was donned as ordered by the physician for 1 of 1 residents reviewed for range of motion. (Resident 35)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Foley (urinary) catheter bags and tubing were kept off of the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 58)

Inspectors wrote2. During an observation on 9/18/24 11:05 a.m. Resident 107 had asked to use the bathroom. At that time, he was wheeled out of the dining room by RN 1 and assisted back to his room. The Medical Record Supervisor (who was also a CNA) assisted RN 1 in placing the resident on the toilet. At that time, RN 1 was asked to lift up the resident's shirt so his peg tube (a tube that was inserted directly into the stomach for nutrition) could be observed. The peg tube was intact and there was dried crusty drainage around the stoma site. There was no bandage covering the stoma site. During an interview on 9/18/24 at 11:09 a.m., RN 1 indicated he has flushed the tube on his shift but he has never cleaned around it. After he had checked in the computer, he indicated there were no orders for the peg tube site to be cleaned. The record for Resident 107 was reviewed on 9/19/24 at 10:55 a.m. [...]

Inspectors wrote2. On 9/16/24 at 11:18 a.m. and 12:22 p.m., Resident 55 was observed wearing oxygen via nasal cannula. The oxygen flow rate was on at 3 liters. The record for Resident 55 was reviewed on 9/17/24 at 3:11 p.m. The diagnoses included, but were not limited to, anoxic (no oxygen to the brain) brain damage, dysphagia (difficulty swallowing), hypertension (high blood pressure), vegetative state (severe brain damage), and chronic obstructive pulmonary disease (COPD). The Quarterly Minimum Data Set (MDS) assessment, dated 8/12/24, indicated the resident was severely impaired for daily decision making and the resident required oxygen therapy. A Care Plan, dated 2/8/24, indicated the resident required oxygen therapy. Interventions were to monitor signs of respiratory distress and to administer oxygen settings via nasal cannula per oxygen orders. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents observed during medication pass. Two errors were observed during 33 opportunities for errors during medication administration. This resulted in a medication error rate of 6.06%. (Residents 3 and 126)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had seen the dentist at least yearly for 1 of 2 residents reviewed for dental care. (Resident 88)

Inspectors wroteBased on record review and interview, the facility failed to ensure clinical records were accurate and complete related to 15 minute checks for a resident who had pushed another resident down to the ground for 1 of 1 residents reviewed for abuse. (Resident 94)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control practices were in place related to hand hygiene during glove use for 1 of 1 glucometer blood sugar checks observed, staff failing to donn personal protective equipment (PPE) for a resident who was in enhanced barrier precautions (EBP), and ensuring Foley (urinary) catheter bags were not on the floor during random infection control observations. (Residents 3, 36, and 113)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the Indiana Department of Health (IDOH) immediately or within the 2 hour time period for 1 of 6 residents reviewed for abuse. (Resident B) The facility also failed to ensure the allegation submitted was not misleading with the facts reported, related to the dates of the allegation, names of residents possibly involved, description of the area at the time of the allegation, and the description of the allegation. (Residents B & C)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was discharged in a safe manner and the facility completed guardianship papers timely for 1 of 3 residents reviewed for discharge. (Resident B)

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions related to expired food in the reach in cooler, a dirty oven hood, grease build up on the stove, as well as touching food items with a gloved hand and the lack of hand hygiene after glove removal. This had the potential to affect the 125 residents who received their meals from the kitchen. (The Main Kitchen)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with ADL's (activities of daily living) related to nail care for 4 of 7 residents reviewed for ADL's. (Residents 63, 27, 35, and 68)

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty and stained floor tiles, marred walls, stained privacy curtains, dirty baseboards, and improper storage of wash basins and bed pans for 3 of 3 units. (North, South and PCU)

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 during the day for 1 of 2 residents reviewed for dignity. (Resident 63)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Comprehensive Minimum Data Set (MDS) assessments were accurately completed related to hospice care, anticoagulant use, and tracheostomy care for 3 of 30 MDS assessments reviewed. (Residents 24, 37, and 60)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with diagnoses of mental illness received a new Level 1 PASARR (Preadmission Screening and Resident Review) for 1 of 1 residents reviewed for PASARR. (Resident 22)

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete a Care Plan related to hospice care and oxygen use for 1 of 30 Care Plans reviewed. (Resident 37)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an ongoing activity program was implemented for alert and oriented, cognitively impaired, and dependent residents for 2 of 5 residents reviewed for activities. (Residents 63 and 10)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure areas of skin discoloration and scabbing were assessed and monitored for 2 of 2 residents reviewed for skin conditions non-pressure related. (Residents 97 and 45)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 2 residents reviewed for accidents. (Resident 52)

Inspectors wroteBased on observation, record review, and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 1 of 1 residents reviewed for intravenous care. (Resident 379)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide proper respiratory care and services related to oxygen at the correct flow rate for 2 of 2 residents reviewed for oxygen. (Residents 37 and 35)

Inspectors wroteBased on record review and interview, the facility failed to monitor a fluid restriction for a resident receiving hemodialysis for 1 of 1 residents reviewed for dialysis. (Resident 46)

Inspectors wroteBased on record review and interview, the facility failed to ensure there was an adequate indication for the use of a hypnotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 52)

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. (PCU)

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the puree recipe for scrambled eggs, sausage, and waffles for the 1 resident who received a pureed diet from the kitchen. (Main Kitchen)

Inspectors wroteBased on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to medication administration and a dialysis access site for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for dialysis. (Residents 24 and 46)