Aperion Care Lincoln failed to provide the wound care treatments as ordered for Resident C, who had type 2 diabetes and a surgical wound, according to federal inspectors who visited the facility September 24.
The resident's physician had ordered the wound vacuum to be changed every three days starting August 8. Electronic treatment records showed the device was scheduled for changes on September 7 and September 10.
Neither treatment occurred.
The Director of Nursing confirmed during a September 24 interview that Resident C's wound vacuum was not changed on either scheduled day. The nursing director spoke with inspectors at 12:32 p.m., acknowledging the missed treatments directly.
Resident C was cognitively intact according to the most recent assessment from July 21, meaning they would have been aware of the missed treatments. The resident's clinical record showed they had been diagnosed with type 2 diabetes mellitus without complications, a condition that can slow wound healing and increase infection risks.
Federal inspectors reviewed three residents' wound care during their visit. Only Resident C experienced missed treatments.
The facility's own policy, titled "Skin Condition Assessment and Monitoring" and last revised in June 2018, required staff to initial the electronic Treatment Administration Record after each treatment. The policy stated that nursing measures not involving medications "shall be documented in the weekly wound assessment or nurses note."
The Administrator provided this policy to inspectors at 3:02 p.m. on September 24, hours after the Director of Nursing had already admitted the treatments were skipped.
Wound vacuum therapy uses controlled suction to remove fluid from wounds and promote healing. The devices require regular changes to maintain proper function and prevent complications. For surgical wounds on diabetic patients, consistent treatment schedules are particularly important because diabetes can impair the body's natural healing processes.
The inspection occurred in response to a complaint. Federal regulators classified the violation as causing "minimal harm or potential for actual harm" to residents.
Aperion Care Lincoln operates at 1236 Lincoln Avenue in Evansville. The facility is part of the Aperion Care network, which operates nursing homes across multiple states.
The missed treatments represent a failure to meet professional standards of quality care, inspectors determined. Federal regulations require nursing facilities to ensure all services meet these standards, including following physician-ordered treatment schedules.
Electronic treatment records at the facility tracked when wound vacuum changes were due, creating a clear paper trail of the missed September 7 and September 10 treatments. The system was designed to help staff stay current with required care, yet the treatments were skipped anyway.
The inspection report does not indicate whether Resident C's wound condition worsened due to the missed treatments or whether the facility eventually completed the overdue wound vacuum changes. It also does not specify what caused staff to skip the scheduled treatments or whether other residents experienced similar lapses in wound care.
The facility must submit a plan of correction to address the deficiency. The inspection was completed September 24, and the violation was assigned Event ID 155820 in federal tracking systems.
For diabetic patients with surgical wounds, consistent wound vacuum therapy can mean the difference between proper healing and serious complications. The missed treatments at Aperion Care Lincoln left Resident C without ordered medical care for days, despite the facility's own policies requiring documentation of all treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aperion Care Lincoln from 2025-09-24 including all violations, facility responses, and corrective action plans.