Inspection Reports for
Aperion Care Tolleston Park

This citation relates to Intake 2701897. The allegation involved inappropriate touching of Resident B by a staff member, reported by Resident C. The allegation was substantiated by the investigation findings that the facility failed to properly investigate and follow up.

The facility failed to conduct a thorough investigation of the abuse allegation for Resident B. The investigation lacked interviews with other residents and staff, no psychosocial follow-up was performed, and no family or responsible party was notified.

The visit was complaint-related, addressing Intake 2693418 and Intakes 2651445 and 2693418.3.1-37(a). The complaints involved failure to complete ADLs, medication administration errors, and incomplete neurological assessments post-fall.

The facility failed to ensure dependent residents received proper ADL care, including showering and bathing documentation. Additionally, medications were not administered as ordered for some residents, and neurological assessments following an unwitnessed fall were incomplete.

This citation relates to Complaint IN0044958.

The facility failed to ensure a resident with a pressure ulcer received treatment as ordered by the physician, and failed to ensure correct Personal Protective Equipment (PPE) was used by staff when caring for a COVID-19 positive resident.

Complaint IN00449958 was substantiated with federal and state deficiencies cited related to allegations about pressure ulcer treatment and infection control practices.

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.

This citation relates to Complaint IN00446462.

The facility failed to complete adequate neurological assessments following a fall for 1 of 3 residents reviewed. Specifically, neurological checks were not documented every four hours as required by facility policy and physician orders.

Complaint IN00446462 was substantiated with federal/state deficiencies cited at F684 related to inadequate neurological assessments following a fall for Resident B.

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.

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.

This Federal tag relates to Complaint IN00436414. The complaint was substantiated based on observations and interviews confirming environmental deficiencies.

The facility failed to maintain a clean and well-repaired environment in multiple units, including dirty and discolored floor tiles, marred walls, broken mini blinds, rusty and missing toilet bolt covers, and missing caulk around toilets. Maintenance and housekeeping supervisors acknowledged the issues and were working on corrections.

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.

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.

The facility was found to have multiple deficiencies including failure to maintain resident privacy, incomplete activities of daily living care, incomplete treatment and medication administration, improper respiratory care, inadequate dental care, inaccurate clinical records, infection control lapses, and environmental cleanliness and maintenance issues.

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.

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.

This citation relates to Complaints IN00427929 and IN00427936. The allegation involved Resident B being burned by his roommate, Resident C. The facility's investigation was ongoing, and the abuse allegation was deemed false by the Administrator based on lack of physical evidence.

The facility failed to report the abuse allegation to the Indiana Department of Health within the required two-hour timeframe and submitted a misleading report that omitted key details such as dates, involved residents, and description of the alleged injury. The investigation was ongoing at the time of the report.

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.

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.

This citation relates to Complaint IN00421025. The complaint involved concerns about the resident's discharge process, lack of guardianship paperwork, and failure to provide behavioral health services during the resident's stay.

The facility failed to ensure safe discharge procedures and timely completion of guardianship paperwork for Resident B. The resident was discharged Against Medical Advice (AMA) without proper care planning or behavioral health services, and guardianship paperwork was not completed promptly despite APS involvement.

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.

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.

Complaint IN00415961 was investigated during this survey and Federal/State deficiencies related to the allegations were cited at F921.

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.

This Federal tag relates to Complaint IN00415961.

The facility failed to maintain a clean and well-repaired environment in multiple units, including dirty and stained floor tiles, marred walls, stained privacy curtains, dirty baseboards, and improper storage of wash basins and bed pans across the North, South, and PCU units.

The facility had multiple deficiencies including failure to maintain resident dignity, inaccurate assessments, incomplete care plans, inadequate assistance with activities of daily living, improper respiratory and dialysis care, medication administration issues, unsafe medication storage, food preparation and sanitation problems, and environmental cleanliness and maintenance issues.

This Federal tag relates to Complaints IN00411300 and IN00405274. The investigation found substantiated deficiencies related to personal funds management, care plan conference invitations, pressure ulcer care, and range of motion exercises.

The facility was found deficient in providing quarterly personal funds statements to residents or their responsible parties, inviting residents to care plan conferences, obtaining treatment orders for a deep tissue injury, and ensuring range of motion exercises were completed as per care plans. Deficiencies were noted for multiple residents with minimal harm and few residents affected.

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.

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.

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.

This Federal tag relates to Complaint IN00404473.

The facility failed to maintain a sanitary and homelike environment, with 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 cleanliness and maintenance issues observed in multiple resident rooms.

Complaint IN00400881 and IN00402975 had no deficiencies related to the allegations. Complaint IN00404473 had federal/state deficiencies cited at F921 related to environmental conditions.

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.

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.

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.

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.

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.

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 investigations included allegations of resident dignity violations, abuse reporting failures, inadequate assistance with ADLs, skin and wound care deficiencies, vision and foot care lapses, medication errors, food service issues, infection control breaches, environmental cleanliness and safety concerns, and pest control problems.

The facility was found deficient in maintaining resident dignity related to use of disposable plates, timely reporting of abuse allegations, providing assistance with activities of daily living, proper skin and wound care, ensuring vision and foot care follow-up, medication management including pain and unnecessary drugs, serving food at proper temperature and times, infection control practices, environmental cleanliness and repair, and pest control.