Aperion Care Lincoln: Sexual Abuse Investigation Failures - IN
There was no written investigation. No documentation of what happened. No formal record that anyone at the facility had ever looked into whether Resident T, a woman described in an anonymous tip as someone not capable of giving sexual consent, had been protected from further contact with the man who had propositioned her.
Inspectors from the Centers for Medicare and Medicaid Services arrived at the Evansville facility on September 24, 2025, following a complaint. What they found was a facility that had responded to a potential sexual abuse allegation almost entirely off the books.
The Director of Nursing described the incident to inspectors during a 9:24 a.m. interview. A certified nurse aide had come to her a few weeks earlier, she said, reporting that Resident B had gone into Resident T's room and asked her to be his girlfriend and whether she had ever had sex. Resident T said no. Resident B left.
The Director of Nursing said she completed a capacity for sexual consent assessment for both residents at that time. She told Resident B he could not ask those questions to other residents.
She indicated there was no other documentation surrounding the incident.
Two hours later, at 11:00 a.m., the Director of Nursing added a detail she had not mentioned in the first interview: the certified nurse aide had also reported that Resident T showed Resident B her breasts.
That detail changed the picture. The original anonymous complaint had flagged two things, not one. Resident B had asked Resident T for sex and to see her breasts. The anonymous source had also stated that Resident T was not capable of giving consent. The Director of Nursing had been told both things by the aide. She mentioned only the verbal exchange in her first account to inspectors.
The administrator, interviewed at 1:04 p.m., confirmed he knew about the incident. He said both residents had been interviewed and the event had come up in a morning meeting. He also confirmed there was no documentation about the incident or any investigation into it.
The facility's own policy, revised just over a year before the incident and provided to inspectors by the administrator at 2:27 p.m., was unambiguous. It stated that the facility would conduct an investigation and protect the resident from non-consensual sexual relations any time there was reason to suspect a resident did not wish to engage in sexual activity or might not have the capacity to consent. It required the facility's interdisciplinary team to assess whether sexual activity was consensual and document the findings in a progress note or plan of care.
None of that happened. The policy sat in a binder. The incident sat in no binder at all.
The Regional President of Operations was also interviewed, at 1:10 p.m. She told inspectors that both residents had been determined to have the capacity to consent. She said she had personally spoken with Resident T.
Then inspectors asked her how the facility had determined whether someone was cognitively able to give consent.
She said she was unsure.
She also said she could not provide any documentation related to an investigation of the incident.
The question of capacity is not incidental here. The anonymous complaint that triggered the inspection specifically stated that Resident T was not capable of giving consent. That allegation required a response. It required documentation of how the facility evaluated Resident T's cognitive state, what criteria they used, who made the determination, and what the basis was. The Regional President of Operations, the person who told inspectors both residents had capacity, could not explain how that conclusion had been reached.
What the facility appears to have done is this: a nurse aide reported a troubling interaction to the Director of Nursing. The Director of Nursing spoke to Resident B, completed some form of capacity assessment, and concluded the situation did not require formal investigation or written documentation. The administrator learned about it at a morning meeting. The Regional President of Operations spoke with Resident T at some point. And then nothing was written down.
That sequence might look, from the inside, like a response. A CNA reported. A supervisor acted. A conversation was had. The resident seemed okay.
From the outside, and from the perspective of the facility's own written policy, it was not a response. It was a series of verbal exchanges that left no record of whether Resident T was safe, whether her capacity had been properly evaluated, whether she had experienced something she did not want and could not refuse, and whether anything had been done to prevent it from happening again.
The inspection report notes the level of harm as minimal harm or potential for actual harm. That designation reflects what inspectors could document, not necessarily what Resident T experienced. The facility's failure to investigate thoroughly means there is no record of what she said when someone asked her about the incident, no record of whether she understood what had happened, and no record of whether she felt safe.
The Regional President of Operations said she talked with Resident T. That conversation, whatever it contained, exists only in memory.
Aperion Care Lincoln operates at 1236 Lincoln Avenue in Evansville. The inspection was completed September 24, 2025, and the deficiency was cited under the federal regulation governing protection from abuse.
The certified nurse aide who first reported the incident to the Director of Nursing did what aides are supposed to do. She saw something and told someone. What happened after that, the handoff from a verbal report to a formal investigation with documentation and a protection plan, is where the facility's process broke down entirely.
Resident T's name is not in the inspection report. Neither is her diagnosis, her age, or what she said to the Regional President of Operations when they spoke. The anonymous source who filed the complaint believed she was not capable of giving consent. The facility concluded she was. Nobody wrote down why.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
APERION CARE LINCOLN in EVANSVILLE, IN was cited for abuse-related violations during a health inspection on September 24, 2025.
There was no written investigation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.