The incident at Life Care Center of Kennewick on August 21 triggered an immediate jeopardy citation from federal inspectors, who found the facility's cook had no process for safely reheating food in microwaves.
Resident 48, who requires assistance with eating due to stroke and aphasia, was wheeled to the dining room by their significant other at 12:43 PM when they told nursing assistant Staff R they were hungry and wanted lunch. Staff R retrieved a tray from the kitchen containing a plate warmer with steam rising from under the lid.
When Staff R tried to remove the hot plate using bare fingers, they quickly dropped it back into the warmer. Staff R then grabbed the plate again with bare hands, placed it in front of Resident 48, and walked away without warning about the temperature or staying to help with eating.
Resident 48 immediately grabbed a spoon and took a bite of mashed potatoes and gravy. The resident began flailing their arms and legs, reached for juice and water, and yelled to their significant other "it's hot, it's hot." Eight seconds passed before the significant other could provide water and juice. Resident 48 continued grimacing in pain, stating "that was hot, it burned my mouth."
Cook Staff S told inspectors they had microwaved Resident 48's plate "for a minute or more" and checked the temperature of the meat, vegetables, and mashed potatoes, finding all foods reached 165 degrees. Staff S admitted they didn't log temperatures for reheated foods and "did not have a process to follow for reheated food using the microwave."
The nursing assistant who served the meal told inspectors: "Did you see me burn my fingers on that plate? It was hot." Staff R acknowledged there was no process for reheated foods from the kitchen and they "just assume it was the right temperature." They added the plate "burned my fingers" and they "should have taken the tray back to the kitchen and not served a plate that was that hot to the resident."
An Advanced Registered Nurse Practitioner examined Resident 48's mouth shortly after the incident. The resident reported a burning sensation, and the provider found "a little area that had contact," predicting sensitivity over the next two to three meals and ordering mouthwash.
The next day, inspectors observed a reddened, raised area on the right side of Resident 48's tongue. The resident rated their pain at 1 out of 10 but said they had to use milk in their breakfast oatmeal to cool it because their mouth remained sensitive.
A denture care provider who examined Resident 48 on August 22 documented that the "patient stated their denture does not hurt at all, they said they burnt their tongue when trying to eat their mashed potatoes."
Administrator Staff A acknowledged "there were missed steps in their process, and it would be good to fix it."
The facility's own policy required food reheated in microwaves not be served above 150 degrees Fahrenheit. The immediate jeopardy citation was removed August 22 after the facility implemented mandatory education with return demonstrations for all dietary and nursing staff on proper microwave reheating, temporarily removed all microwaves until training was complete, and prohibited nursing staff from reheating or serving food that appeared hot.
Inspectors found additional safety violations throughout the facility. In two shower rooms, cleaning agents containing Oxivir TB solution were left unsecured in unlocked areas accessible to residents. The chemical poses hazards if consumed or contacts eyes. Follow-up observations over multiple days showed the violations persisted.
Eight personal protective equipment carts in resident hallways contained unsecured Sani-Cloth Bleach Germicidal wipes on their tops. Safety data sheets showed the wipes could injure eyes or skin on contact. Director of Nursing Staff B acknowledged "all the cleaning agents should be stored in a secured manner such as in locked areas so that the residents were not able to get into contact with them."
The facility also failed to coordinate proper dialysis care for residents receiving life-sustaining treatments at an outside center. For Resident 9, who receives dialysis three times weekly, five communication forms between July and August were returned incomplete from the dialysis center with no documentation about the resident's condition or post-treatment weight. Despite facility policy requiring nurses to call the center for missing information, no progress notes showed any attempts to obtain the data.
Resident 44's dialysis communication included two forms sent to the center without the required pre-treatment assessment and one form returned blank with no follow-up documented.
A four-month delay in dental care left another resident without dentures despite repeated requests. Resident 33, who is edentulous and told staff "it kind of bums you out when you don't have teeth," received a denturist referral in April that Social Services Assistant Staff Q never scheduled. The resident said having teeth "would make it easier to eat."
Essential equipment failures compounded resident care problems. One of three commercial washing machines had been broken for approximately a month, unable to drain water properly. Maintenance Director Staff C received the repair report in June but failed to follow standard procedures for timely follow-up with the outside vendor.
Laundry Assistant Staff D described bins of soiled resident laundry "filled to the top" and having to "run all day to get the laundry done" with only two functioning machines. Nursing Assistant Staff E reported residents were "always short on clothing" and "yesterday a resident didn't have pants, not because they don't have enough clothing, but because the washer was broken."
In the kitchen, a janitor's closet storing disinfection chemicals and cleaning supplies had a non-functioning exhaust fan, allowing chemical fumes to build up. Food Service Director Staff F was unaware the fan wasn't working and said kitchen staff weren't responsible for periodic inspections. Maintenance Director Staff C also didn't know about the broken motor and admitted to not regularly inspecting the exhaust system.
Administrator Staff A acknowledged the non-functioning exhaust fan "could cause fumes from the cleaning and disinfecting chemicals" and "could potentially cause problems with inhalation of chemical fumes due to build up of potential gases; it could cause illness or breathing issues."
The August 26 inspection found a facility struggling with basic safety protocols across multiple departments, from food service to maintenance, leaving residents vulnerable to preventable injuries and inadequate care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Kennewick from 2024-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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