Inspection Report
Complaint Investigation
Census: 126
Capacity: 126
Deficiencies: 0
Jul 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458176.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00458176 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 6
Medicaid census: 110
Other payor census: 10
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 24, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00449958.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00449958 completed on January 24, 2025; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 129
Capacity: 129
Deficiencies: 2
Jan 22, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449958, which involved federal and state deficiencies related to allegations concerning pressure ulcer treatment and infection control.
Findings
The facility failed to ensure a resident with a pressure ulcer received necessary treatment as ordered, and failed to ensure correct Personal Protective Equipment (PPE) was used by staff when caring for a COVID-19 positive resident. Deficiencies related to pressure ulcer treatment and infection prevention and control were cited.
Complaint Details
Complaint IN00449958 was substantiated with federal and state deficiencies cited related to allegations about pressure ulcer treatment and infection control practices.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to treatments not completed as ordered. | SS=D |
| Failure to ensure correct Personal Protective Equipment (PPE) was used by a staff member when cleaning a room where a COVID-19 positive resident resided. | SS=D |
Report Facts
Census: 129
Total Capacity: 129
Medicare Residents: 6
Medicaid Residents: 111
Other Payor Residents: 12
Survey Dates: 3
Audit Frequency: 3
Audit Frequency: 2
Audit Frequency: 1
PPE Audit Frequency: 5
PPE Audit Frequency: 4
PPE Audit Frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Dawson | Director of Nursing | Named in relation to pressure ulcer treatment findings and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 16, 2024
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of Complaint IN00446462 completed on November 21, 2024.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Complaint IN00446462 was investigated and found to be in compliance based on the paper review.
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 1
Nov 21, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446462 regarding allegations related to quality of care.
Findings
The facility failed to complete adequate fall follow-up related to missing neurological assessments for 1 of 3 residents reviewed for falls (Resident B). The neurological checks were not documented every four hours as required by facility policy.
Complaint Details
Complaint IN00446462 was substantiated with federal/state deficiencies cited at F684 related to inadequate neurological assessments following a fall for Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to complete adequate fall follow-up related to missing neurological assessments for Resident B. | SS=D |
Report Facts
Census: 125
Total Capacity: 125
Medicare residents: 8
Medicaid residents: 110
Other residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Bensema | Administrator | Signed the report |
| Director of Nursing | Interviewed regarding neurological assessment policy and documentation |
Inspection Report
Life Safety
Census: 125
Capacity: 180
Deficiencies: 0
Nov 20, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/03/24 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this Life Safety Code survey, Aperion Care Tolleston Park was found in compliance with Medicare/Medicaid participation requirements and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered except for a detached wood equipment storage shed which was unsprinklered.
Report Facts
Certified beds: 180
Dually certified beds: 152
Medicare only beds: 28
Census: 125
Inspection Report
Life Safety
Census: 131
Capacity: 180
Deficiencies: 6
Oct 3, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with locked egress gates on the lockdown unit, sprinkler system maintenance, smoking area safety, improper use of extension cords, and oxygen cylinder storage. Corrective actions were planned for each deficiency.
Severity Breakdown
SS=E: 5
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through 1 of 1 exit gates on the lockdown unit were readily accessible; gate was locked with a padlock requiring a key not readily available. | SS=E |
| Failed to maintain ceiling construction in 1 of 7 smoke compartments; gap between ceiling and sprinkler escutcheon plate. | SS=E |
| Failed to ensure 1 of 1 smoking areas and 1 of 1 kitchen areas were maintained by disposing cigarette butts in metal or noncombustible containers with self-closing covers. | SS=E |
| Failed to ensure 1 of 1 extension cords were not used as a substitute for fixed wiring to provide power to high current draw equipment. | SS=D |
| Failed to ensure approximately 10 of 10 oxygen cylinders were segregated from full and empty cylinders and marked to avoid confusion. | SS=E |
| Failed to ensure a minimum distance of at least five feet separated combustible materials from oxygen storage equipment in 2 of 2 oxygen trans-filling rooms; wooden shelves were less than five feet from transfilling area. | SS=E |
Report Facts
Certified beds: 180
Census: 131
Dually certified beds: 152
Medicare only beds: 28
Residents potentially affected by locked egress gate: 15
Residents and staff potentially affected by sprinkler gap: 30
Residents and staff potentially affected by smoking regulation deficiency: 15
Staff potentially affected by extension cord deficiency: 4
Residents potentially affected by oxygen cylinder storage deficiency: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Bensema | Administrator | Named during exit conference and signature on report |
| Maintenance Director | Interviewed and involved in observations and corrective actions | |
| Maintenance Assistant #1 | Interviewed and involved in observations and corrective actions | |
| Assistant Maintenance Director | Mentioned as key holder for padlock on exit gate |
Inspection Report
Annual Inspection
Census: 123
Capacity: 123
Deficiencies: 13
Sep 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of multiple complaints.
Findings
The facility was found deficient in multiple areas including personal privacy, ADL care, quality of care, encoding/transmitting assessments, range of motion care, catheter care, tube feeding management, respiratory care, medication error rates, dental services, resident records, infection control, and environmental conditions.
Complaint Details
This survey included the investigation of complaints IN00436414, IN00437098, IN00437481, IN00440036, IN00440148, and IN00442228. Deficiencies related to complaint IN00436414 were cited at F921. No deficiencies were related to the other complaints.
Severity Breakdown
SS=D: 12
SS=A: 1
SS=E: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Staff failed to knock on residents' doors prior to entering, violating personal privacy for 2 residents. | SS=D |
| Failed to complete and export Discharge Minimum Data Set assessment within required timeframe for 1 resident. | SS=A |
| Failed to ensure activities of daily living (ADLs) were completed for dependent residents related to nail care and shaving for 3 residents. | SS=D |
| Failed to ensure non-pressure ulcer treatments were completed as ordered and psychiatric consult obtained as ordered for 2 residents. | SS=D |
| Failed to ensure a palm protector was donned as ordered for 1 resident. | SS=D |
| Failed to keep Foley catheter bags and tubing off the floor for 1 resident. | SS=D |
| Failed to ensure tube feeding was infusing at correct time and treatment orders obtained for gastrostomy tube site for 2 residents. | SS=D |
| Failed to ensure oxygen was set at correct flow rate for 2 residents. | SS=D |
| Medication error rate exceeded 5% due to insulin pen not primed and administration of discontinued medication for 2 residents. | SS=D |
| Failed to ensure a resident had seen the dentist at least yearly for 1 resident. | SS=D |
| Failed to ensure clinical records were accurate and complete related to 15 minute checks for 1 resident with abuse incident. | SS=D |
| Failed to ensure infection control practices including hand hygiene, PPE use, and catheter bag placement were followed for 3 residents. | SS=D |
| Failed to ensure residents' environment was clean and in good repair related to dirty/discolored floors, marred walls, broken blinds, rusty toilet bolts, missing bolt covers, and missing caulk in multiple rooms. | SS=E |
Report Facts
Census: 123
Total Capacity: 123
Medication error rate: 6.06
Audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Bensema | Administrator | Signed the report |
| ADON 2 | Assistant Director of Nursing | Interviewed regarding multiple deficiencies including privacy, ADL care, quality of care, catheter care, respiratory care, infection control |
| LPN 1 | Observed administering insulin without priming pen | |
| LPN 2 | Observed administering discontinued medication | |
| RN 1 | Interviewed regarding gastrostomy tube care | |
| Nurse Consultant | Provided policies and interviewed about medication and infection control practices | |
| Director of Nursing | Interviewed regarding oxygen flow rates, catheter care, and environmental issues | |
| Social Service Director | Interviewed regarding dental care scheduling |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 20, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00436414 completed on September 20, 2024.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure Survey and complaint investigation.
Complaint Details
Investigation of Complaint IN00436414 was completed and found in compliance.
Inspection Report
Complaint Investigation
Census: 132
Capacity: 132
Deficiencies: 0
Jun 6, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432501, IN00434965, and IN00435073.
Findings
No deficiencies related to the allegations in complaints IN00432501, IN00434965, and IN00435073 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00432501, IN00434965, and IN00435073 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 132
Total Capacity: 132
Medicare Census: 9
Medicaid Census: 117
Other Payor Census: 6
Inspection Report
Complaint Investigation
Census: 131
Capacity: 131
Deficiencies: 0
Mar 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429675.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00429675 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 131
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 117
Census Payor Type - Other: 4
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 29, 2024
Visit Reason
Paper compliance review of the Investigation of Complaints IN00427929 and IN00427936 completed on February 8, 2024.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00427929 and IN00427936, with compliance found upon paper review.
Inspection Report
Complaint Investigation
Census: 135
Capacity: 135
Deficiencies: 2
Feb 8, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427929 and IN00427936 regarding allegations of abuse at the facility.
Findings
The facility failed to report an allegation of abuse to the Indiana Department of Health immediately or within the required 2-hour timeframe for 1 of 6 residents reviewed. Additionally, the facility submitted a misleading report regarding the allegation, including inaccurate dates, involved residents, and description of the incident.
Complaint Details
The investigation was triggered by complaints IN00427929 and IN00427936 alleging abuse of Resident B by his roommate. The facility delayed reporting the allegation to the Indiana Department of Health and submitted an inaccurate report omitting key details such as the roommate's involvement and the condition of the resident at the time of the allegation. The allegation was ultimately deemed false by the Administrator after investigation, but the reporting deficiencies were cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse immediately or within 2 hours as required. | SS=D |
| Submission of a misleading allegation report with inaccurate facts related to dates, residents involved, and description of the allegation. | SS=D |
Report Facts
Residents reviewed for abuse: 6
Census: 135
Total licensed capacity: 135
Medicare residents: 9
Medicaid residents: 121
Other payor residents: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Frank Bensema | Administrator | Named in relation to the delayed reporting and investigation of the abuse allegation |
Inspection Report
Complaint Investigation
Census: 139
Capacity: 139
Deficiencies: 0
Jan 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00420811 and IN00424117.
Findings
No deficiencies related to the allegations in Complaints IN00420811 and IN00424117 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00420811 and Complaint IN00424117 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 139
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 126
Census Payor Type - Other: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 22, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00421025 completed on November 6, 2023.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00421025 completed on November 6, 2023; facility found in compliance based on paper review.
Inspection Report
Life Safety
Deficiencies: 0
Nov 15, 2023
Visit Reason
The visit was a Post Survey Revisit (PSR) related to the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/12/2023.
Findings
Aperion Care Tolleston Park was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 139
Capacity: 139
Deficiencies: 1
Nov 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421025 regarding federal and state deficiencies related to discharge planning and resident safety.
Findings
The facility failed to ensure a resident was discharged in a safe manner and did not complete guardianship paperwork timely for one of three residents reviewed for discharge. The resident was discharged Against Medical Advice (AMA) by her son without proper discharge planning or involvement of guardianship processes, despite concerns of elder abuse and cognitive impairment.
Complaint Details
Complaint IN00421025 was substantiated with federal/state deficiencies cited related to discharge planning and resident safety. The resident was cognitively impaired, had suspected elder abuse, and was discharged AMA by her son without proper discharge planning or guardianship. The facility failed to follow up on guardianship paperwork and did not hold care planning conferences with the resident or family regarding discharge or long-term care placement.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was discharged in a safe manner and timely completion of guardianship paperwork for a resident with cognitive impairment and suspected elder abuse. | SS=D |
Report Facts
Census: 139
Total Capacity: 139
Medicare Census: 11
Medicaid Census: 124
Other Payor Census: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Attinger | RVP of Operations | Signed report and provided interview regarding discharge and guardianship follow-up |
| Social Service Director | Interviewed regarding resident admission, discharge, and guardianship process | |
| Director of Nursing | Interviewed regarding resident discharge and awareness of APS case | |
| Business Office Manager | Interviewed regarding guardianship paperwork follow-up and communication with Medical Director |
Inspection Report
Re-Inspection
Census: 137
Capacity: 180
Deficiencies: 2
Oct 30, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code deficiencies cited on 09/12/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included a resident room corridor door that did not latch properly and a smoking area not maintained with proper disposal containers for cigarette butts.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 30 resident room corridor doors on the 100 wing had a means suitable for keeping the door closed, latching, and resisting the passage of smoke, affecting approximately 2 residents in room 113. | SS=D |
| Failed to ensure 1 of 2 smoking areas was maintained by disposing cigarette butts in a metal or noncombustible container with self-closing cover devices, affecting approximately 12 residents and staff. | SS=E |
Report Facts
Certified beds: 180
Census: 137
Dually certified beds: 152
Medicare only beds: 28
Resident room corridor doors inspected: 30
Residents potentially affected by door deficiency: 2
Smoking areas inspected: 2
Residents potentially affected by smoking area deficiency: 12
Cigarette butts observed: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Attinger | RVP of Operations | Signed the report |
| Maintenance Director | Interviewed regarding door and smoking area deficiencies | |
| Executive Director | Participated in exit conference discussing deficiencies |
Inspection Report
Re-Inspection
Census: 143
Capacity: 143
Deficiencies: 0
Oct 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 25, 2023, including the PSR to the Investigation of Complaint IN00415961 completed on August 25, 2023.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Complaint IN00415961.
Complaint Details
Complaint IN00415961 was investigated and found to be corrected.
Report Facts
Census SNF/NF beds: 143
Census Medicare residents: 12
Census Medicaid residents: 124
Census Other residents: 7
Inspection Report
Routine
Census: 126
Capacity: 180
Deficiencies: 16
Sep 12, 2023
Visit Reason
Routine Life Safety Code Recertification and Emergency Preparedness Survey conducted by the Indiana Department of Health in accordance with 42 CFR regulations.
Findings
The facility was found not in compliance with Emergency Preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, policies, procedures, communication plan, and training/testing. Life Safety Code deficiencies included issues with exit door locking, blocked exit discharge, outdated battery-operated smoke alarms, fire door inspections not completed, missing elevator firefighter recall tests, incomplete fire drill documentation, improper smoking area maintenance, and improper use of power strips and extension cords.
Severity Breakdown
F: 7
E: 5
D: 1
C: 1
B: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to review and update Emergency Preparedness Plan annually. | F |
| Failed to review and update Emergency Preparedness Policies and Procedures annually. | F |
| Failed to review and update Emergency Preparedness Communication Plan annually. | F |
| Failed to review and update Emergency Preparedness Training and Testing Plan annually. | F |
| Exit door in main lobby locked with incorrect code, not readily accessible for egress. | E |
| Exit discharge blocked by a vehicle. | E |
| Battery-operated smoke alarms in resident rooms over 10 years old. | E |
| Fire alarm system out-of-service policy incomplete; missing IDOH Gateway notification instructions. | F |
| Sprinkler system out-of-service policy incomplete; missing IDOH Gateway notification instructions. | F |
| Corridor doors in 100 wing did not latch properly and had impediments blocking closure. | D |
| Elevator firefighter recall testing missing for 6 of 12 months. | C |
| Missing fire drills on second and third shifts for multiple quarters. | F |
| Smoking area not maintained; cigarette butts disposed on ground instead of proper containers. | E |
| Annual inspection and testing of 5 fire door assemblies not documented. | F |
| Non-hospital grade electrical receptacles in 100 and 200 wings not tested annually. | E |
| Power strip daisy chaining and use of extension cords as substitute for fixed wiring. | B |
Report Facts
Certified beds: 180
Census: 126
Battery-operated smoke alarms over 10 years old: 4
Elevator firefighter recall missing months: 6
Fire drills missing: 3
Fire door assemblies: 5
Resident rooms with non-hospital grade receptacles: 61
Power cord daisy chains: 2
Extension cords used improperly: 2
Inspection Report
Annual Inspection
Census: 127
Capacity: 127
Deficiencies: 19
Aug 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00415961.
Findings
The facility was found deficient in multiple areas including resident dignity, notification of hospital transfers, accuracy of assessments, care planning, ADL assistance, activity programming, skin condition monitoring, fall precautions, PICC line care, oxygen therapy, fluid restriction monitoring, psychotropic medication use, medication storage, food preparation and sanitation, medical record accuracy, and environmental cleanliness and repair.
Complaint Details
Complaint IN00415961 was investigated during this survey and Federal/State deficiencies related to the allegations were cited at F921.
Severity Breakdown
SS=D: 13
SS=E: 2
SS=F: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure resident dignity related to wearing a hospital gown during the day for 1 of 2 residents reviewed. | SS=D |
| Failed to notify resident's Responsible Party in writing related to a hospital transfer for 1 of 3 residents reviewed. | SS=A |
| Failed to ensure 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. | SS=D |
| Failed to ensure a resident with mental illness received a new Level 1 PASARR for 1 of 1 residents reviewed. | SS=D |
| Failed to complete a Care Plan related to hospice care and oxygen use for 1 of 30 Care Plans reviewed. | SS=D |
| Failed to ensure dependent residents received assistance with nail care for 4 of 7 residents reviewed. | SS=E |
| Failed to ensure an ongoing activity program was implemented for alert and oriented, cognitively impaired, and dependent residents for 2 of 5 residents reviewed. | SS=D |
| 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. | SS=D |
| Failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 2 residents reviewed for accidents. | SS=D |
| Failed to care for a PICC line in accordance with professional standards related to flushing the PICC line for 1 of 1 residents reviewed for intravenous care. | SS=D |
| Failed to provide proper respiratory care and services related to oxygen at the correct flow rate for 2 of 2 residents reviewed for oxygen. | SS=D |
| Failed to monitor a fluid restriction for a resident receiving hemodialysis for 1 of 1 residents reviewed for dialysis. | SS=D |
| Failed to ensure adequate indication for the use of a hypnotic medication for 1 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to ensure a controlled substance was double locked at all times for 1 of 2 medication rooms observed. | SS=D |
| Failed to follow the puree recipe for scrambled eggs, sausage, and waffles for the 1 resident who received a pureed diet from the kitchen. | SS=D |
| Failed to store and serve food under sanitary conditions related to expired food, dirty oven hood, grease build up on stove, and improper glove use and hand hygiene in the kitchen. | SS=F |
| Failed to maintain clinical records that were complete and accurately documented related to medication administration and dialysis access site for 1 of 5 and 1 of 1 residents respectively. | SS=D |
| Failed to maintain a safe, functional, sanitary, and comfortable environment 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. | SS=E |
| Failed to ensure annual resident rights, abuse training, and dementia training was completed for 4 of 5 employee records reviewed. | — |
Report Facts
Survey dates: 5
Census SNF/NF: 127
Medicare census: 6
Medicaid census: 117
Other payor census: 4
Narcotic medication sign out missing: 9
Dialysis catheter site checks inaccurate: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Did not complete required annual dementia training for 2022 | |
| Activity Aide 3 | Did not complete required annual dementia training for 2022 | |
| Housekeeper 1 | Did not complete required annual dementia training for 2022 | |
| QMA 1 | Did not complete required annual dementia training for 2022 | |
| LPN 1 | Observed with unlocked controlled substance box in medication room | |
| LPN 2 | Observed administering PICC line medication and flushing | |
| Cook 1 | Observed not following puree recipes and improper glove use | |
| Dietary Food Manager | Provided policy and education on food storage and hand hygiene | |
| Director of Nursing | Provided multiple interviews and education on various deficiencies | |
| Human Resource Director | Acknowledged missing annual training for employees and planned audits | |
| Activity Director | Interviewed regarding activity program deficiencies and staffing | |
| Maintenance Supervisor | Interviewed regarding environmental deficiencies and cleaning | |
| Housekeeping Supervisor | Interviewed regarding environmental deficiencies and cleaning |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of complaints IN00405274 and IN00411300 completed on June 30, 2023.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations IN00405274 and IN00411300, with compliance found upon paper review.
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 4
Jun 29, 2023
Visit Reason
This visit was for the investigation of complaints IN00405274, IN00410278, and IN00411300. The complaints involved allegations related to personal funds accounting, care planning, pressure ulcer treatment, and range of motion exercises.
Findings
The facility was found deficient in providing quarterly statements for residents' personal funds, ensuring residents were invited to care plan conferences, providing necessary treatment orders for pressure ulcers, and completing range of motion exercises for residents with limited mobility.
Complaint Details
Complaint IN00405274 had federal/state deficiencies related to allegations cited at F686. Complaint IN00410278 had no deficiencies related to allegations. Complaint IN00411300 had federal/state deficiencies related to allegations cited at F568, F657, and F688.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure quarterly statements were provided for 2 of 3 residents reviewed for personal funds. | SS=D |
| Failed to ensure residents were invited to their Care Plan conferences for 2 of 3 residents reviewed. | SS=D |
| Failed to ensure residents with pressure ulcers received necessary treatment and services, including lack of treatment orders for a deep tissue injury for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure range of motion exercises were completed for 1 of 3 residents reviewed for limited range of motion. | SS=D |
Report Facts
Census: 125
Total Capacity: 125
Medicare Census: 8
Medicaid Census: 115
Other Payor Census: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Maurice | Administrator | Signed the report and provided information about quarterly statements |
| Social Services Director 1 | Social Services Director | Provided information about care plan conference invitations |
| Social Services Director 2 | Social Services Director | Provided information about care plan conference invitations and invitation system |
| Director of Nursing | Director of Nursing | Provided information about care plan conferences, pressure ulcer treatment, and range of motion documentation |
| Financial Coordinator | Provided information about handling residents' personal funds and quarterly statements | |
| 100 Unit Manager | Observed resident's pressure ulcer and applied heel protector boot |
Inspection Report
Renewal
Deficiencies: 1
May 19, 2023
Visit Reason
The visit was an offsite Licensure Investigation Survey conducted to review the facility's compliance with license renewal requirements.
Findings
The facility failed to submit a renewal application at least 45 days prior to the expiration of their license, as the renewal application and payment were postmarked May 1, 2023, after the license expired on April 30, 2023. The facility license was subsequently renewed.
Deficiencies (1)
| Description |
|---|
| Failure to submit a renewal application at least 45 days prior to license expiration. |
Report Facts
Days prior to license expiration for renewal application submission: 45
License expiration date: Apr 30, 2023
Renewal application postmark date: May 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Attinger | RVP of Operations | Signed the report as the provider/supplier representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 25, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00404473 completed on March 29, 2023.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00404473 completed on March 29, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 132
Capacity: 132
Deficiencies: 1
Mar 29, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00400881, IN00402975, and IN00404473). Deficiencies related to complaint IN00404473 were cited.
Findings
The facility failed to maintain a sanitary and homelike environment, with issues including uncovered and unlabeled urinals, bedpans, and basins stored on bathroom floors, damaged floor tiles, holes and scrapes on walls, missing privacy curtains, strong urine odor, and other maintenance and cleanliness deficiencies observed in 10 of 13 rooms across two units.
Complaint Details
Complaint IN00400881 and IN00402975 had no deficiencies related to the allegations. Complaint IN00404473 had federal/state deficiencies cited at F921 related to environmental conditions.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain a sanitary and homelike environment including uncovered and unlabeled urinals, bedpans, and basins stored on bathroom floors, damaged floor tiles, holes and scrapes on walls, missing privacy curtains, strong urine odor, and other related issues in multiple resident rooms. | SS=E |
Report Facts
Census: 132
Total Capacity: 132
Medicare Census: 19
Medicaid Census: 103
Other Payor Census: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Attinger | RVP of Operations | Signed the report |
| Director of Maintenance | Participated in observation and interview regarding deficiencies | |
| Director of Housekeeping | Participated in observation and interview regarding deficiencies |
Inspection Report
Complaint Investigation
Census: 137
Capacity: 137
Deficiencies: 0
Jan 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00398735 and IN00398983.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00398735 - Substantiated with no deficiencies cited. Complaint IN00398983 - Substantiated with no deficiencies cited.
Report Facts
Census SNF/NF: 137
Total Capacity: 137
Census Payor Type Medicare: 10
Census Payor Type Medicaid: 124
Census Payor Type Other: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2023
Visit Reason
The inspection was conducted as a paper compliance review of the investigation of complaints IN00387641, IN00389137, IN00389274, and IN00396417 completed on December 13, 2022.
Findings
Aperion Care Tolleston Park was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper review of the complaint investigation.
Complaint Details
The visit was related to complaint investigations and the facility was found to be in compliance based on the paper review.
Inspection Report
Complaint Investigation
Census: 141
Capacity: 141
Deficiencies: 3
Dec 12, 2022
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00387641, IN00389137, IN00389274, IN00389949, IN00395081, and IN00396417) at Aperion Care Tolleston Park.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' call lights were within reach for fall-risk residents, failure to maintain comfortable room temperatures due to malfunctioning heaters, and failure to maintain a sanitary and homelike environment with issues such as dirty floors, soiled linens, broken equipment, and improper storage of bedpans and soaps.
Complaint Details
Complaints IN00387641, IN00389137, IN00389274, and IN00396417 were substantiated with related federal/state deficiencies cited. Complaints IN00389949 and IN00395081 were unsubstantiated due to lack of evidence.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure residents' call lights were within reach for 5 residents identified as fall risk. | SS=E |
| Failed to maintain comfortable temperature levels in resident rooms; heaters were off, set too low, or not working properly for 5 of 29 rooms observed. | SS=E |
| Failed to maintain a sanitary and homelike environment; issues included dirty floors, meal trays left in rooms, soiled linens, broken furniture, improper storage of bedpans and soaps, and non-functioning electric beds in multiple rooms and nurses' stations. | SS=E |
Report Facts
Residents observed for call light placement: 26
Resident rooms observed for temperature: 29
Facility census: 141
Facility total capacity: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lakeithia Webb | Executive Director | Signed report and involved in environmental tour acknowledging deficiencies |
| Assistant Maintenance Director | Interviewed regarding heater malfunctions and room temperatures |
Inspection Report
Re-Inspection
Census: 135
Capacity: 180
Deficiencies: 0
Oct 11, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/29/2022.
Findings
At this Post Survey Revisit, Aperion Care Tolleston Park was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility is fully sprinklered except for a detached wood equipment storage shed, and is protected by natural gas and diesel generators.
Report Facts
Certified beds: 180
Census: 135
Generator power: 30
Generator power: 45
Inspection Report
Re-Inspection
Census: 133
Capacity: 133
Deficiencies: 0
Sep 13, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2022-08-05, including a PSR to the Investigation of Complaints IN00384672, IN00384824, and IN00387286 completed on 2022-08-05.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of the three complaints. All complaints were corrected.
Complaint Details
Complaints IN00384672, IN00384824, and IN00387286 were investigated and found to be corrected.
Report Facts
Census Bed Type: 133
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 120
Census Payor Type - Other: 7
Inspection Report
Routine
Census: 133
Capacity: 180
Deficiencies: 12
Aug 29, 2022
Visit Reason
A routine Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found substantially compliant with Emergency Preparedness requirements but had deficiencies related to failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, and Training and Testing Plan. Life Safety Code deficiencies included missing drywall in the electrical room ceiling, obstructions in corridors, fire alarm annunciator panel not properly mounted, sprinkler system maintenance issues, discharged fire extinguisher not mounted, smoke barrier doors not closing properly, incomplete elevator firefighter recall testing, and incomplete generator testing and inspection documentation.
Severity Breakdown
SS=C: 4
SS=D: 2
SS=E: 3
SS=F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=C |
| Failed to review and update Emergency Preparedness Plan's Policies and Procedures at least annually. | SS=C |
| Failed to review and update Emergency Preparedness Plan's Communication Plan at least annually. | SS=C |
| Failed to review and update Emergency Preparedness Plan's Training and Testing Plan at least annually. | SS=C |
| Failed to maintain building construction type due to missing drywall on ceiling in electrical room. | SS=E |
| Failed to maintain means of egress free from obstructions in corridors. | SS=E |
| Failed to maintain fire alarm system properly; annunciator panel was falling off the wall and taped. | SS=F |
| Failed to maintain sprinkler system with proper spare sprinklers and documentation of inspections. | SS=F |
| Failed to ensure portable fire extinguisher was properly mounted; one was discharged and sitting on the floor. | SS=D |
| Failed to ensure smoke barrier doors fully closed and latched to restrict smoke movement. | SS=E |
| Failed to maintain monthly testing of staff elevator firefighter recall for 11 of 12 months. | SS=D |
| Failed to exercise generator monthly for 12 months and maintain weekly inspection records for 4 weeks. | SS=F |
Report Facts
Certified beds: 180
Census: 133
Length of missing elevator firefighter recall testing: 11
Length of missing generator exercise: 12
Length of missing weekly generator inspection records: 48
Length of missing monthly wet sprinkler gauge inspection: 8
Length of missing monthly sprinkler control valve inspection: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness plan, fire alarm system, sprinkler system, fire extinguisher, smoke barrier doors, elevator testing, and generator testing. | |
| Administrator | Interviewed and involved in findings review and exit conference. |
Inspection Report
Annual Inspection
Census: 126
Capacity: 126
Deficiencies: 18
Aug 5, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of multiple complaints.
Findings
The facility was found deficient in multiple areas including resident dignity, reporting of alleged abuse, ADL care, activities, skin care, vision and hearing services, pain management, medication regimen, food service, infection control, resident call system, environment maintenance, and pest control.
Complaint Details
This visit included the Investigation of Complaints IN00384672, IN00384824, IN00385007, IN00386306, and IN00387286. Complaints IN00384672, IN00384824, IN00386306, and IN00387286 were substantiated with related deficiencies cited. Complaint IN00385007 was unsubstantiated due to lack of evidence.
Severity Breakdown
SS=C: 1
SS=D: 9
SS=E: 5
SS=F: 1
SS=B: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to ensure each resident's dignity was maintained related to the use of disposable plates and utensils for meals. | SS=C |
| Failed to report an allegation of alleged physical abuse immediately within 2 hours after the allegation was made. | SS=D |
| Failed to ensure dependent residents were provided assistance with activities of daily living related to eating, nail care, shaving, and showers. | SS=E |
| Failed to ensure a resident was invited and taken to activities. | SS=D |
| Failed to ensure areas of bruising and arterial ulcers were assessed and monitored and treatments completed and signed out. | SS=D |
| Failed to ensure residents with impaired vision received necessary services related to follow-up with referrals to an Ophthalmologist. | SS=D |
| Failed to ensure a resident with a pressure ulcer received necessary treatment and services to promote healing related to treatments not done as ordered and missing bandages. | SS=D |
| Failed to ensure dependent residents received foot care and had routine visits with a podiatrist related to long and thick toenails. | SS=D |
| Failed to ensure a splint was in place as ordered for a resident with limited range of motion. | SS=D |
| Failed to ensure a resident with complaints of pain received scheduled medication to relieve the pain. | SS=D |
| Failed to ensure blood pressure medication was held per parameters and duplicate drug therapy was not ordered. | SS=D |
| Failed to ensure food was served at a palatable temperature. | SS=E |
| Failed to ensure breakfast and lunch meals were served on time for multiple units. | SS=E |
| Failed to store and serve food under sanitary conditions related to unlabeled and undated food and improper handling of food with gloved hands. | SS=F |
| Failed to ensure infection control guidelines were implemented including hand hygiene before meals, proper PPE use in isolation rooms, COVID-19 monitoring, and sanitizing multi-use equipment. | SS=E |
| Failed to ensure residents on the Behavioral Unit had a means to summon for help at the bedside. | SS=E |
| Failed to ensure the residents' environment was clean and in good repair related to cracked floor tiles, dirty and discolored floors, marred walls, and torn chairs. | SS=E |
| Failed to maintain an environment free of pests related to flies in a resident's room and the Memory Care Unit dining room. | SS=B |
Report Facts
Census SNF/NF: 126
Medicare Census: 9
Deficiencies cited: 17
Flies counted: 10
Pressure ulcer measurements: 18
Pressure ulcer measurements: 8
Pressure ulcer measurements: 5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 5
Pressure ulcer measurements: 8
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 3.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Did not wear proper PPE entering isolation rooms and did not perform hand hygiene | |
| RN 1 | Registered Nurse | Did not clean blood pressure cuff between residents |
| Dietary Cook 1 | Handled food with gloved hand without utensils | |
| Director of Nursing | DON | Provided multiple interviews and explanations related to deficiencies |
| Administrator | Provided multiple interviews and explanations related to deficiencies | |
| Dietary Food Manager | Interviewed about food temperature and labeling |
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