Peterson Rehab: Scalding Water Threatens Residents - WV

The most dangerous temperature — 126 degrees Fahrenheit — was recorded in a resident room sink and the shower room serving Wing 1's 20 residents. At that temperature, burns penetrate the entire thickness of skin and permanently destroy tissue within three minutes.

Maintenance Supervisor #73 told inspectors he tested water temperatures once weekly and they averaged around 113 degrees. But when inspectors requested temperature checks on February 9, the readings told a different story.

The supervisor inserted a thermometer into the running water stream in a resident room. The temperature climbed to 126 degrees.

Three shower rooms showed similarly dangerous readings. Wing 1's shower measured 126 degrees. Wing 2's shower reached 121.6 degrees, hot enough for third-degree burns in five minutes. Wing 7's shower hit 122.5 degrees.

Fifty-six of the facility's residents regularly use these three shower rooms. Wing 1 serves all 20 residents on that floor. Wing 2 serves 16 of 18 residents. Wing 7 serves 20 of 21 residents.

The nursing home administrator confirmed during the inspection that the maintenance director would ensure all water temperatures stayed at 110 degrees or below.

Water temperature violations were among several safety and care problems inspectors documented at the 132-bed facility.

Expired insulin sat in medication carts while other vials went undated, creating risks for diabetic residents. Registered Nurse #119 confirmed that one resident's insulin glargine carried no opening date, while another resident's Novolog insulin had expired after the required 28-day disposal period.

The facility's own policy requires multi-dose vials to be dated upon opening and discarded within 28 days. The Director of Nursing confirmed insulin should follow these same rules.

Food service problems left residents with lukewarm meals. When inspectors tested the last lunch tray delivered to Wing 1 residents, temperatures fell well below safe serving standards.

The hamburger measured 116.5 degrees. Carrots reached only 112.2 degrees. Ham registered 104 degrees.

Dietary Aide #300, who conducted the temperature tests, agreed the readings were inappropriate for resident meals. Hot food should reach 120 degrees or above at the point of delivery, the aide said.

The food problems extended beyond temperature. Ice machines throughout the facility violated basic sanitation requirements. Kitchen ice machine drainpipes ran along the floor to drains. Nutrition room ice machines on units one and three had drainpipes touching the drains directly, eliminating the required air gap that prevents contamination.

Units one, five and six operated ice machines without required filters. The Maintenance Director confirmed during the tour that drainpipes should not touch floors or drains, and all ice machines needed filters.

Medical record keeping showed widespread documentation failures affecting seven residents. Forms designed to guide end-of-life care contained critical errors that made them legally invalid.

Two residents signed Physicians Orders for Scope of Treatment forms but failed to date their signatures. The Director of Nursing confirmed undated signatures made the documents legally invalid.

Another resident's POST form showed conflicting selections, with both "selective treatments" and "comfort-focused treatments" marked despite instructions to choose only one option.

One resident with specific doctor's orders prohibiting blood pressure checks on his right arm — where he had vascular access for dialysis — still had blood pressures documented from that protected arm. The resident told inspectors he would not allow anyone to take blood pressures from his right arm and actively protected it.

A transfer form completed at 8:00 AM carried a date stamp showing 12:30 PM, creating confusion about the actual timing of the resident's move.

Basic infection control broke down in at least one case. Inspectors observed Resident #85's urinary catheter drainage bag touching the floor, a violation that can introduce dangerous bacteria into the urinary system.

Nurse Aide #163 acknowledged the problem when inspectors pointed it out, saying "let me raise the bed, it shouldn't be touching the floor." The Director of Nursing confirmed catheter bags should never contact floor surfaces.

The violations occurred across multiple departments and shifts, suggesting systemic problems with safety protocols and staff supervision. Water temperatures that could cause permanent injury, expired medications for diabetic residents, and contaminated ice machines created daily risks for vulnerable residents who depend on the facility for basic care and safety.

Third-degree burns from scalding water present as loss of skin layers and dry, leathery skin that may appear charred or show white, brown, or black patches. The burns often feel painless because nerve endings are destroyed, though surrounding first- and second-degree burns can cause significant pain.

Peterson Rehabilitation's 132 residents trusted the facility to maintain safe water temperatures, properly stored medications, and sanitary food service. Instead, they faced daily exposure to hazards that could cause permanent injury or illness.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Peterson Rehabilitation and Healthcare from 2025-02-13 including all violations, facility responses, and corrective action plans.

Additional Resources

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