Aperion Care Tolleston Park

In the surveyor’s words

From the most serious findings on record at Aperion Care Tolleston Park, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 16, 2022

  Based on observation, record review, and interview, the facility failed to ensure a risk for hazards to residents did not occur related to a resident who was deemed unable to maintain her own smoking materials due to safety, repeatedly keeping her smoking materials on her person without facility intervention, the resident continued to light cigarettes inside the facility, and placed a lit cigarette in the trash can, causing a fire which activated the fire alarm and had to be extinguished. All residents in the facility not residing on the 2 locked, inaccessible units were at risk for fire hazards related to unsafe smoking. […]

• Immediate jeopardy, isolatedF686Jun 11, 2026

  Based on record review and interview, the facility failed to prevent an avoidable pressure ulcer for an at-risk dependent resident resulting in the resident developing a facility-acquired stage four (full thickness of the skin) pressure ulcer with infection to the buttocks one month after admission to the facility. (Resident B)The immediate jeopardy began on 5/26/26, when the nursing staff found a malodorous stage four pressure ulcer to the buttocks which tested positive for infection when cultured. The Administrator, RN Corporate Wound Specialist, RN Consultant, Corporate Minimum Data Set (MDS) Nurse, and Director of Nursing (DON) were notified of the immediate jeopardy on 6/10/26 at 3:06 p.m. […]

• Immediate jeopardy, isolatedF689Nov 18, 2021

  Based on observation, record review and interview, the facility failed to implement adequate supervision measures to prevent a cognitively impaired resident from exiting the building. The resident left the building unattended around 7:45 p.m. on 11/3/21 wearing pajamas and socks and was overheard knocking on the door he exited from 50 minutes later. The resident was assessed upon his return and transferred to the facility's secure unit. The facility is located within 1 mile of a major interstate and adjacent to a busy 2 lane road. (Resident B) The immediate jeopardy began on 11/3/21 when the resident had exited the facility without supervision or knowledge of facility staff. The resident was able to exit from the North door. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2023

  Based on observation and interview, the facility failed to store and serve food under sanitary conditions related to expired food in the reach in cooler, a dirty oven hood, grease build up on the stove, as well as touching food items with a gloved hand and the lack of hand hygiene after glove removal. This had the potential to affect the 125 residents who received their meals from the kitchen. (The Main Kitchen) Findings include: 1. Observation during the initial kitchen tour, on [DATE] at 9:15 a.m. with the Dietary Food Manager (DFM), indicated the following: a. There were 3 bowls of pudding, dated [DATE], in the reach in cooler. b. The flour scoop was stored directly in the flour. c. The oven hood had a heavy accumulation of dirt and grease noted in all the slats. d. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2022

  Based on observation and interview, the facility failed to store and serve food under sanitary conditions related to food not labeled and dated and touching food items with a gloved hand. This had the potential to affect the 126 residents who received their meals from the kitchen. (The Main Kitchen) Finding includes: Observation during the initial kitchen tour, on 7/31/22 at 8:51 a.m. with the Dietary Food Manager (DFM), indicated the following: a. A stainless steel container in the reach in cooler containing an orange substance that was not labeled or dated. There was also a stainless steel container of applesauce that was not dated and 3 plastic containers of sliced peaches that were not dated. Interview with the DFM at that time, indicated the items should have been dated. b. […]