Aperion Care Lincoln
APERION CARE LINCOLN in EVANSVILLE, IN — inspection on September 24, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
authorities.
the State Survey Agency for 1 of 1 allegation of abuse reviewed. (Resident T)Finding includes:In an
breasts, and that Resident T was not capable of giving consent.
During an interview on 9/24/25 at 9:24 A.M., the Director of Nursing (DON) indicated that a few weeks prior, a Certified Nurse Aide (CNA) had reported to her that Resident B went into Resident T's room and asked her to be his girlfriend and if she had ever had sex.
Resident T responded no and Resident B left.
The DON was unable to remember when that incident occurred.
During an interview on 9/24/25 at 11:00 A.M., the DON indicated that the CNA also reported to her that Resident T showed Resident B her breasts.
She indicated that the incident occurred on or around 8/23/25.
During an interview on 9/24/25 at 1:04 P.M., the Administrator indicated he was aware of the incident that occurred between Resident B and Resident T. He was unaware it needed to be reported to the State Survey Agency.
During an interview on 9/24/25 at 1:10 P.M., the Regional [NAME] President of Operations indicated that she was aware of the incident that occurred between Resident B and Resident T, but was unaware that it needed to be reported to the State Survey Agency.
During an interview on 9/24/25 at 2:27 P.M., the Administrator indicated that the facility did not have a policy related to reporting alleged violations and followed State regulations.This citation relates to Intake 2608809.3.1-28(c) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155820 09/24/2025
Aperion Care Lincoln 1236 Lincoln Ave Evansville, IN 47714
During the course of the investigation of an allegation of resident sexual abuse or other situation as warranted, the Interdisciplinary Team shall assess and make a determination of whether the sexual activity was consensual on the part of the resident(s) and document the findings of the assessment in a progress note and/or in the plan of care.This citation relates to Intake 2608809.3.1-28(d)
155820 09/24/2025
Aperion Care Lincoln 1236 Lincoln Ave Evansville, IN 47714
includes:On 9/23/25 at 1:39 P.M., Resident C's clinical record was reviewed.
Resident C's diagnoses
Minimum Data Set (MDS) Assessment, dated 7/21/25, indicated Resident C was cognitively intact, and had a surgical wound.
Physician orders included, but were not limited to: Wound vac to be changed every three days; Start Date 8/8/25 The electronic treatment administration record indicated Resident C's wound vac was scheduled to be changed on the following days in September 2025, but was not changed:9/7/259/10/25
During an interview on 9/24/25 at 12:32 P.M., the Director of Nursing indicated Resident C's wound vac was not changed on 9/7/25 or 9/10/25. On 9/24/25 at 3:02 P.M., the Administrator provided a policy titled Skin Condition Assessment and Monitoring, revised 6/2018, that indicated Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration.
Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses note.' This citation relates to Intake 2615547. 3.1-35(g)(1)
155820 09/24/2025
Aperion Care Lincoln 1236 Lincoln Ave Evansville, IN 47714
During an observation on 9/23/25 at 1:00 P.M., Resident C indicated that bathing had not been completed or bed linen hadn't been changed in weeks.
Resident C had a very pungent sour smell, greasy hair, and long, soiled fingernails.
The point of care (POC, a certified nurses aide charting system) indicated Resident C preferred bathing twice weekly in the evenings.
Paper and electronic shower records were reviewed for the last 30 days, and indicated Resident C had not received or refused a bath or shower on the following dates: 8/26/259/12/259/19/25 The bathing records indicated Resident C had not had their hair shampooed from 8/26/25 through 9/23/25. On 9/24/25 at 2:27 P.M., the Administrator provided a policy titled Bathing Shower and Tub Bath, revised 1/2018, that indicated A shower, tub bath, or bed/sponge bath will be offered according to the resident's preference, two times per week or according to the resident's preferred frequency and as needed or requested.
This citation relates to Intake 2588834. 3.1-38(a)(3)
155820 09/24/2025
Aperion Care Lincoln 1236 Lincoln Ave Evansville, IN 47714
make a determination of whether the sexual activity was consensual on the part of the resident(s)
155820 09/24/2025
Aperion Care Lincoln 1236 Lincoln Ave Evansville, IN 47714
Based on observation, interview, and record review, the facility failed to ensure proper storage of
medication refrigerator were not locked. (First Floor Medication Room)Finding includes: On 9/23/25 at 1:04 P.M., the first floor medication room that contained the Emergency Drug Kit (EDK) was observed unlocked.
Inside the room, the treatment cart and the refrigerator that contained insulin, suppositories, and other cold medication was observed unlocked. At that time, Qualified Medication Aide (QMA) 16 indicated that the medication room, treatment cart, and medication refrigerator were all supposed to be locked.On 9/24/25 at 2:27 P.M., the Administrator provided a current Medication Storage policy, revised 7/2/19, that indicated Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.This citation relates to Intake 2615731.3.1-25(m)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.