MINDEN, La. Town & Country Health & Rehab gave a resident a second-degree burn from scalding coffee on January 15, 2025, then did nothing about it for more than three months: no investigation, no temperature checks, no staff training, no corrective action of any kind.
That's not an allegation. That's what the facility's own administrator told inspectors when they arrived on April 30, 2025.
"Today was the first I've heard about it," the administrator said.
The burn earned the facility an Immediate Jeopardy citation, the most serious classification available to federal surveyors, reserved for situations where a facility's failures create a risk of serious harm or death. Inspectors classified the deficiency as affecting many residents. At the time surveyors arrived, 95 residents had the ability to be harmed by the same unaddressed failure.
The nursing home sits on Weston Street in Minden, in northwestern Louisiana's Webster Parish.
The administrator confirmed he had not conducted any investigation into how Resident #72's burn occurred. He had not interviewed the certified nursing assistant who served the coffee. He had no idea how hot that coffee was when it reached the resident.
The Director of Nursing said she could not find any investigation. She could not locate any corrective actions. She could not find documentation of what temperature the coffee was when Resident #72 was burned.
The Dietary Manager learned about the incident for the first time from inspectors. "Today was the first time she had heard anything about a concern regarding the temperature of the coffee," the inspection report states, "because Resident #72 was burned with coffee back in January."
That single sentence tells you everything about how this facility handled a resident getting a second-degree burn.
Coffee at Town & Country was brewed using 196-degree-Fahrenheit water. No one checked the temperature before pouring it into pump dispensers and rolling it out to residents. Staff reheated coffee in microwaves. Cups were filled to the top. Residents with tremors, weakness, or limited cognitive function received the same open, brimming cups as anyone else.
A review of staff training records covering May 2024 through April 30, 2025, nearly a full year, turned up zero training on hot liquids or burn prevention. The facility had a written policy requiring a thorough investigation of burns. Nobody followed it.
Inspectors also asked for scald prevention policies on April 30. None were provided.
The Immediate Jeopardy finding forced the facility into emergency mode the same day. The administrator and Director of Nursing sat through a training session with a Regional Supervisor that afternoon on incident investigation and reporting. Kitchen staff got instruction on tempering coffee before service. CNAs were told to stop reheating coffee in microwaves, to fill cups only halfway, and to offer lids to residents at risk for spills. The ADON delivered that training to nursing staff at 1:15 p.m. on April 30.
The facility's fix for coffee that brewed at 196 degrees: add a scoop of ice after brewing to bring the temperature down to 130 to 135 degrees Fahrenheit before serving.
The Regional Supervisor told inspectors during a May 22 telephone interview that he was also researching a coffee brewer that operates at 125 degrees and was considering ordering one to test. For the moment, the ice-dump method was the solution.
By the time surveyors returned on May 22, 2025, when the inspection was completed, the corrective measures appeared to be holding. Kitchen temperature logs from April 30 through May 22 showed daily checks, with no reading above 135 degrees. Incident logs for the same period showed no burn-related events. Resident #72 told an inspector she had not been burned again. Staff now served her coffee in a disposable cup with a lid.
Staff interviews on May 22 showed the training had reached the floor. A CNA described the protocols in detail: no reheating, no overfilling, lids for high-risk residents, fresh cup if the coffee cools. An LPN added that residents with Parkinson's or tremors now received cups with sip-through spouts. The Dietary Manager confirmed temperature checks before every service, with ice added post-brewing to hit the target range.
An inspector watched two CNAs work the snack and hydration cart for 20 minutes that morning. The cart held insulated 12-ounce to-go cups with snap-on lids. One CNA served the inspector a demonstration cup, filled halfway, lidded, at a palatable temperature. Kitchen records showed that batch at 125 degrees. The CNA did not conduct a formal temperature check at the cart.
Inspectors interviewed six residents who drank coffee during morning rounds. None reported burns. Resident #72 said her coffee now came in a lidded cup and she was fine.
The Immediate Jeopardy was removed April 30, 2025, the day the corrective actions began.
A separate deficiency (F0908, rated minimal harm) cited two industrial gas dryers in the facility's laundry with heavy lint buildup on their filters and on the floor of the filter compartment. One dryer had a three-to-four-inch pile of lint in the back right corner. The facility's own maintenance policy required daily lint cleaning. The laundry worker who showed inspectors the dryers confirmed the buildup exceeded three loads' worth and needed to be addressed.
That finding is a footnote. The burn is the story.
A resident suffered a documented second-degree burn at this facility. The burn required no elaborate detective work to investigate. The same CNA who served the coffee was still employed and on the floor. The kitchen that brewed the coffee was still operating. The incident happened in January. The administrator did not know about it in late April.
Inspectors classified the Immediate Jeopardy deficiency under F0835, the tag governing accident prevention, and rated it as affecting many residents at the most serious level of harm the survey system recognizes.
Town & Country Health & Rehab's plan of correction committed to weekly monitoring of all incident reports by the administrator, twice-weekly kitchen temperature checks on Mondays and Thursdays, and ongoing staff training. A May 19 training covered steps for staff to take if an adverse event occurs.
Resident #72 drinks her coffee from a lidded cup now. The question the inspection record leaves open is what it took. The answer: a second-degree burn, four months of inaction, and an unannounced federal survey before anyone thought to check the temperature of the coffee served every morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Town & Country Health & Rehab from 2025-05-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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