Aperion Care Vincennes: Hot Water Burns Resident - IN
The resident, identified in inspection records only as Resident C, raised the head of her bed using the remote control. The cup tipped. The water spilled across her torso and traveled to her back. Inspectors noted her skin was red and blisters were already forming before she was sent to the hospital.
By the next morning, the blisters had opened.
Wound assessments documented over the following day told the full scope of what the water had done. On her abdomen: a partial-thickness burn measuring 34 centimeters long and 10 centimeters wide, with 60 percent of the wound surface described as bright pink or red, and pain rated at 5 out of 10. On her lower left back: a second partial-thickness burn, 19 centimeters by 12 centimeters, with 70 percent of the wound surface bright pink or red, also rated at a 5 for pain. By the following morning, a third burn had been documented on her left hip, 15 centimeters by 8 centimeters, the entire wound surface bright pink or red.
Three separate burns. All facility-acquired. All from a single cup of water.
The Director of Nursing, interviewed by inspectors on September 18, acknowledged that staff were expected to monitor the temperature of heated liquids before serving them to residents. She also acknowledged there was no documentation, and no indication of any kind, that anyone had checked the temperature of the water given to Resident C.
The facility had a written policy on this. The administrator produced it during the same visit, a document titled "Precautions for Handling Hot Beverages," dated 2020. The policy directed staff to monitor, serve, and hold hot beverages in a safe manner to prevent burns. It called for identifying residents at high risk of burning themselves and ensuring staff monitored those residents when hot beverages were served.
Nobody had done any of that.
After the burn, the facility moved quickly on paper. Staff received in-service training on the policy for heating food and beverages. Thermometers were placed near the microwaves. Signs went up in the dining areas reminding staff to check temperatures. The Director of Nursing told inspectors these corrective steps had been taken.
The policy requiring temperature checks had existed since 2020. The thermometers and the signs came after Resident C was sent to the hospital with open blisters across her midsection.
Federal inspectors cited the facility under the tag covering freedom from accident hazards, finding that the failure to monitor the water temperature before serving it was a deficient practice that caused actual harm. The inspection, triggered by a complaint, was completed September 23, 2025.
Resident C had adjusted her own bed. That was the last act she controlled in the sequence. Everything before it, the decision to microwave the water for two and a half minutes, the decision to bring it to her bedside, the decision not to check its temperature, belonged to staff.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aperion Care Vincennes from 2025-09-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
APERION CARE VINCENNES in VINCENNES, IN was cited for violations during a health inspection on September 23, 2025.
The resident, identified in inspection records only as Resident C, raised the head of her bed using the remote control.
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.