Failure to Prevent Burns from Hot Liquids Due to Lack of Individualized Interventions and Hazard Identification
Summary
The facility failed to implement individualized care planned interventions to prevent a resident with significant physical disabilities from sustaining multiple burns. The resident, who had diagnoses including Spastic Cerebral Palsy, Scoliosis, Dysphagia, and Muscle Spasms, required supervision or assistance with eating and was dependent on staff for all other activities of daily living. Despite these needs, the resident was allowed to handle hot coffee independently, resulting in two separate incidents where hot coffee was spilled on her left posterior thigh, causing second-degree burns on both occasions. The care plan did not include a hot liquid risk assessment, and interventions to prevent such injuries were either not in place or not followed by staff. The facility also failed to identify the hot water/coffee dispenser in the main dining room as a potential burn hazard. The dispenser was accessible to all residents, and the coffee and hot water were routinely served at temperatures ranging from 170 to 177 degrees Fahrenheit, well above the threshold known to cause burns. There were no protocols or adequate monitoring in place to ensure that hot liquids were served at safe temperatures. Staff interviews revealed a lack of awareness regarding residents' care plans and the need for assistance with hot liquids, and some staff did not know how to access or update care plans. Additionally, the dining room doors were sometimes left open or unlocked, allowing residents unsupervised access to the hot beverage dispenser. The facility did not have a Hot Liquids Policy in place prior to the incidents, and staff were not in-serviced on the risks associated with hot liquids or the need for individualized interventions. The lack of a systematic approach to assessing residents' risk for hot liquid injuries, combined with inadequate staff training and supervision, directly contributed to the resident's repeated injuries. The failures affected not only the resident who was burned but also placed all 59 residents who accessed the hot beverage dispenser at risk.
Removal Plan
- All residents were interviewed by V8/Wound Nurse, V22/Restorative Nurse, V23/Business Office Manager, and V24/Social Service Director for hot liquid spills with injury.
- R1 was removed from the dining room, laid down, clothes were removed, and a head-to-toe skin assessment was completed. V7/R1's Physician and V25/R1's Family member was notified. A wound dressing was ordered, R1's care plan was updated to ensure staff assisted R1 with a waterproof clothing protector and lap blanket to be worn during all meals and as needed for food and fluid intake and to continue Occupation therapy three times a week for twelve weeks.
- A Hot Liquid Policy was developed and implemented.
- A Hot Liquid Risk Assessment was developed and implemented.
- V1/Administrator in-serviced Department Managers (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the facility's Hot Liquid Policy. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- All residents, including R1, were assessed with the facility hot liquids assessment to determine if they are at risk of being injured.
- R1's care plan was updated to include interventions for hot liquid spills with injury and for Speech Therapy to Evaluation and Treat.
- The facility implemented utilizing colored napkins to alert each member of the team that the resident is at high risk for burn injury.
- All at risk residents for being injured due to hot liquids were identified on meal tray cards.
- V4/MDS Coordinator updated all resident care plan with interventions that were identified as at risk for spilling hot liquids causing injuries.
- The coffee machine in the main dining room was disconnected.
- The coffee machine was removed from the main dining room. Coffee and other hot liquids are being served from the kitchen and temped prior to being served.
- A new coffee machine was ordered and will be dispensed at 150 degrees Fahrenheit.
- Waterproof adult clothing protectors and waterproof blankets were ordered for the residents identified at risk for injury from hot liquid.
- A Food Temperature Log for Meal Services was implemented with coffee/hot water to be served at 150 degrees Fahrenheit or less.
- V1 in-serviced each department manager (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, and that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- A system was put in place for an audit to be done by V2/Director of nursing, for five residents daily, five days a week, for six weeks to ensure compliance with interventions being put in place. V2/Director of Nursing is utilizing the audit tool to ensure care plan interventions are being followed. These are monitored/audited for compliance by V1/Administrator one time per week.
- V4/MDS Coordinator reviewed and updated R1 and the residents identified to be at risk for injury from hot liquids care plans.
- V1/Administrator provided all staff in-servicing regarding the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- V1/Administrator in-serviced all Agency Staff regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit, and the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- A copy of the facility's Hot Liquid Policy was added to the new orientation manual and the agency orientation manual.
- A system was put in place for an audit to be done by V3/Dietary Manager, for five residents daily, five days a week, for six weeks to ensure compliance with temperatures of hot liquids prior to being served to ensure they are below the appropriate temperatures. V3/Dietary Manager is utilizing this audit form to ensure hot liquids are being served at appropriate temperatures. These are monitored/audited for compliance by V1/Administrator once time per week.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility failed to keep the environment free of accident hazards when a resident’s room contained an unattended shaving razor on the sink and additional razors in a nightstand, despite leadership stating razors were not permitted in resident rooms. An LPN disposed of unused lancets in regular trash instead of a sharps container, contrary to acknowledged policy. On two occasions, an unattended housekeeping cart on an upper floor had germicidal wipes left on top and easily accessible, even though housekeeping leadership and staff stated that chemicals and disinfectant wipes were to be kept locked in the cart for safety.
A resident with severe cognitive impairment, dementia, a history of falls, and dependence on staff for transfers was observed using a lift reclining chair even though the care plan and physical device review did not identify that device. Therapy staff lowered the chair and placed the remote next to the call light on the resident’s lap, and staff stated they were not aware of any formal assessment for safe use of the lift chair. The DON stated the resident should have had an assessment to determine whether she was safe to have the lift chair.
A resident with severe cognitive impairment, dementia with behavioral disturbances, and fall risk interventions in place was transferred by staff using methods that did not match the care plan and Kardex. Staff used a transfer belt for some transfers, then later used a Hoyer lift from mattresses on the floor to a wheelchair, but used a green sling even though the resident required a yellow sling based on weight. The RN, LPN, DON, and PT verified the resident’s transfer status and sling instructions were not updated to reflect current needs.
A resident with nicotine dependence was care planned as a smoker who could go out to smoke at designated times or with family, with an intervention that a smoking evaluation be completed quarterly. The last documented smoking safety evaluation showed the resident could safely smoke with supervision, but no additional evaluations were completed for several months, contrary to facility policy requiring smoking assessments at admission, readmission, with significant change, and quarterly by a licensed nurse, even though the resident continued to smoke under staff and family supervision in the courtyard.
Failure to supervise smokers and secure smoking materials. Surveyors found that 27 smokers were not adequately monitored and that residents were able to keep cigarettes and lighters in their possession despite care plan directions to return them after smoking. One resident with severe cognitive impairment, dementia, schizophrenia, and continuous oxygen use was observed with cigarettes and a lighter while on oxygen, and staff confirmed she was an unsafe smoker requiring direct supervision.
Code Alert System Failed to Prevent Resident Elopement: The facility failed to keep the code alert system functioning as intended and did not follow the manufacturer’s weekly testing and inspection guidance. Two residents with significant cognitive impairment were able to get through the main doors, and one resident exited the building before staff followed outside. The report also states that multiple residents with code alert devices did not have adequate elopement or wandering assessments and care plan interventions, and several attempts to leave were not documented in the record.
Failure to Control Razors, Sharps, and Chemical Wipes Creating Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safe handling of potentially hazardous items. On one floor, a shaving razor was observed on the sink in a resident’s room. When questioned, the resident stated the razor on the sink was not his and showed the surveyor separate razors he kept in his nightstand. The resident’s record showed admission with malignant neoplasm of overlapping sites of the bladder and care plans for ADL self-care deficits related to activity intolerance, generalized muscle weakness, bladder cancer, and a history of gross hematuria, with interventions including encouraging and assisting with bathing, personal hygiene, and oral care. Facility leadership, including the ADON, Administrator/Risk Manager, and DON, stated that residents were not allowed to keep shaving razors in their rooms and that razors were to be kept in the supply room. Additional observations showed that staff did not consistently follow safe disposal practices for sharps and did not secure chemical products as required by facility policy. An LPN performing a blood glucose check discarded unused lancets into the medication cart trash instead of a sharps container, despite acknowledging that lancets were to be disposed of in a sharps-resistant container. On two separate observations, a housekeeping cart on the second floor was left unattended with a container of germicidal wipes placed on top of the cart and easily accessible. Corporate housekeeping staff and the Housekeeping Director stated that all chemicals that could harm residents should be locked in the cart’s compartment, and housekeeping staff reported that disinfectant wipes and cleaning supplies were to be kept locked in the cart for resident safety. The facility’s written “Nursing Home Accident Prevention and Safety Policy” stated a commitment to maintaining a safe, hazard-free environment and identifying and correcting safety risks promptly.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. The facility continues to ensure that the resident environment remains free of accident hazards as possible. IMMEDIATE CORRECTIVE ACTION Resident #29 was not adversely affected by the alleged deficient practice. Razor was immediately removed and disposed of from resident's room by nurse on 5/11/26. Germicidal wipes were immediately secured in a locked housekeeping cart on 5/11/26. Staff E was provided with 1:1 education by the Director of Nursing regarding the importance of providing an environment free from hazards and accidents with emphasis on keeping hazardous items like razor secured on 5/11/26. Staff G was provided with 1 to 1 education by House Keeping Director regarding ensuring that all housekeeping chemical products are secured in a locked housekeeping cart when not in use on 5/12/2026. IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED All active residents in the facility can potentially be affected by the alleged deficient practice. The Director of Nursing and/ designee conducted a facility-wide observation audit to ensure that hazardous items are locked and secured and that staff are disposing of Sharps in a Sharp Resistant Container on 05/15/2026. The Housekeeping Director conducted a facility-wide observation on 5/15/2026 to ensure that all housekeeping chemical products were secured and locked inside the housekeeping cart when not in use. No residents were adversely affected by the alleged deficient practice. SYSTEMATIC CHANGES Director of Nursing initiated ongoing in-service education with staff on standards of maintaining an environment free from hazards/accidents with emphasis on keeping hazardous items like razor secured and properly disposing of sharps in sharps resistant container on 5/20/26. The Housekeeping Director and/or designee initiated ongoing in-service education on standards of maintaining an environment free from hazards/accidents with emphasis on keeping housekeeping chemical products secured and locked in a housekeeping cart when not in use on 5/20/2026. MONITORING The Director of Nursing and/or designee will conduct random observation audits to ensure that hazardous items are locked and secured and sharps are disposed in sharps resistant container weekly for 3 months. The Housekeeping Director and/or designee will conduct random observation audits to ensure that housekeeping chemical products are secured and locked in a housekeeping cart weekly for 3 months. The Director of Nursing, Housekeeping Director and/or designee will report findings of observation/audits to the quality assurance committee monthly for 3 months to ensure continued substantial compliance is achieved and maintained.
Failure to Assess Safe Use of Lift Reclining Chair
Penalty
Summary
The facility failed to ensure a resident was safe to have a lift reclining chair. The resident had severe cognitive impairment, lower extremity impairment on one side of the body, a history of falls, dependence on staff for transfers, and diagnoses including dementia, disorientation, anxiety, muscle weakness, and a right pubis fracture. The resident’s care plan identified high fall risk related to impaired mobility, confusion, and dementia, and directed staff to keep the call light within reach and encourage use of it. The care plan also stated the resident required two staff to assist with transfers using a standing lift as needed, but it did not identify use of a lift reclining chair. The physical device review also did not identify an electric recliner chair or other lift type reclining chair. During observation, the resident was transferred into the lift chair by therapy staff, who lowered it from an upright position to a seated and then reclining position. The remote for the lift chair and the call light were both placed on the resident’s lap next to each other. The PTA stated she was not aware of any assessment for safe use of the lift chairs, and nursing and therapy staff stated they were not aware of any formal lift chair assessment for the resident. The DON stated therapy worked with residents who had lift chairs and was not aware of any formal assessment, and later stated the resident should have had an assessment completed to determine if she was safe to have a lift chair. The DON also stated the resident was cognitively impaired and could accidentally use the lift chair remote when intending to push the call light.
Failure to Follow Transfer and Sling Size Interventions
Penalty
Summary
The facility failed to ensure staff followed fall risk interventions for one resident identified as at risk for falls. The resident had severe cognitive impairment, delusions, behaviors directed at others, dementia with behavioral disturbances, anxiety, an affective disorder, diabetes, and hearing loss. The resident’s care plan and Kardex identified the resident as a fall risk and stated the resident was independent for transfers, while also noting that if a Hoyer transfer was required, a yellow/medium sling was to be used. During observation, nursing assistants transferred the resident from a wheelchair to the toilet using a transfer belt, then later transferred the resident from the wheelchair to mattresses on the floor using a transfer belt and two staff members. Staff stated they normally used a Hoyer lift to lift the resident from the mattresses on the floor, but the resident’s Kardex did not identify the mattresses on the floor or clarify when a Hoyer should be used for transfers. Staff also stated the resident was not independent with transfers and required one to two staff for wheelchair-to-toilet transfers and two staff with a Hoyer for transfers to and from the mattresses on the floor. On a later observation, two nursing assistants used a Hoyer lift to transfer the resident from the mattresses on the floor to a wheelchair, but used a green sling even though the resident weighed 155 pounds and the manufacturer’s chart indicated a yellow sling was required. Staff stated the green sling was too big for the resident and that the correct sling size was important for safety. The RN, LPN, DON, and PT all verified that the resident’s care plan and Kardex were not revised to reflect the resident’s current transfer abilities and the correct sling size and transfer method for the resident’s current setup.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
The facility failed to ensure resident safety related to smoking by not completing required smoking safety assessments at the prescribed frequency for one resident. A resident with a diagnosis that included nicotine dependence was observed smoking in the courtyard with his daughter present, and later in the presence of Activities staff who remained outside with the residents while they smoked. The resident’s care plan, dated 2/4/25, identified him as a smoker who could go out to smoke at designated times or with family and specified that a smoking evaluation would be completed quarterly. Record review showed the most recent Smoking Safety Evaluation had been completed on 11/6/24 and indicated the resident could safely smoke with supervision, but no further evaluations were completed until 4/30/26, despite facility policy requiring smoking assessments upon admission, readmission, with significant change, and quarterly by a licensed nurse.
Failure to Supervise Smokers and Secure Smoking Materials
Penalty
Summary
The facility failed to adequately supervise 27 identified smokers and failed to secure resident smoking materials, including lighters and cigarettes. Surveyors found that the facility’s smoking policy required smoking-related privileges, restrictions, and concerns to be documented in the care plan and communicated to personnel, and required residents with restricted smoking privileges to be monitored under direct supervision while smoking. Resident #15 was observed sitting up in bed with oxygen in use, and later was observed on the smoking patio sitting in a wheelchair with a plastic bag containing cigarettes and a lighter in her lap. Staff confirmed she was identified as an unsafe smoker and required a smoking apron while smoking. Her record showed severe cognitive impairment with a BIMS score of 6, diagnoses including dementia and schizophrenia, and continuous oxygen at 2 liters per minute via nasal cannula for COPD. Review of the records for all 27 smokers showed care plan interventions requiring them to return smoking materials to the Activities Department after re-entering the building from the smoking patio. Interviews with the Activity Director, LPN, MDS staff, CNA, DON, Administrator, and Medical Director showed conflicting descriptions of where smoking materials were kept, but multiple staff acknowledged that residents kept cigarettes and lighters in their possession and that residents were expected to turn them in after smoking. The Medical Director stated residents were not permitted to keep cigarettes or lighters and that residents with low BIMS scores or those receiving oxygen should not have access to smoking materials.
Code Alert System Failed to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the code alert system used for residents at risk for elopement was functioning properly and failed to follow the manufacturer’s recommendations for weekly testing and inspection. The report states that the immediate jeopardy began when R12 was able to exit the building after the main entrance code alert system malfunctioned, and that R19 was also able to get through the main doors because the doors did not lock as required by the system. The manufacturer’s binder in the facility called for weekly testing of the code alert units, regular testing of each detection zone, and quarterly service inspections, but the facility’s logs showed the doors were being tested monthly instead of weekly. R19 was severely cognitively impaired with Alzheimer’s disease. The resident’s assessment identified low elopement risk, and the care plan lacked interventions for elopement and wandering. During observation, R19 wheeled to the main entrance, went through the first door into the vestibule, and the alarm sounded, but the door did not lock. A nursing assistant responded and redirected R19 back to the central TV area. The resident’s progress note did not include the attempt to leave the building. R12 was severely cognitively impaired with non-Alzheimer’s dementia and anxiety. The resident had repeated attempts to leave the facility, but the care plan lacked elopement and wandering interventions, and the most recent assessment also identified low elopement risk with the door alarm band not selected. During observations, R12 repeatedly approached the main entrance, triggered the alarm, and was able to get through the first door into the vestibule; on one occasion R12 exited the building before being followed outside by staff. The report also states that R12’s record lacked documentation of the successful exit and other attempts to leave. In addition, the facility failed to adequately assess and develop care plans for multiple other residents assigned code alert devices, including residents with severe or moderate cognitive impairment and diagnoses such as dementia and Alzheimer’s disease, whose care plans did not include elopement or wandering interventions or, in some cases, the location of the device.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.