The April 12 incident at Renaissance Rehabilitation and Nursing Care Center involved Resident #7, who told staff they had spilled the hot beverage the evening before. Licensed Practical Nurse #15 discovered blisters on the resident's left upper thigh and contacted a nurse practitioner for treatment orders.
Nobody investigated further.
The Director of Nursing admitted during a November inspection interview that no root cause analysis was completed for the accident, despite facility requirements. They said such an analysis "should have been completed by the Director of Nursing or other facility staff."
More troubling, the Director of Nursing wasn't even informed about the burn until two days later, on April 14. They acknowledged they should have been notified immediately since no registered nurse was in the building when the incident occurred.
The resident burned again.
After reviewing electronic medical records during the inspection interview, the Director of Nursing found that "the only intervention put in place after the 04/12/2025 accident was resident education." They could not locate any other measures to prevent similar incidents.
A registered dietitian had recommended providing lids with beverages for Resident #7 after the first burn. That recommendation sat unimplemented for months. The safety measure wasn't entered into the resident's care plan or certified nursing aide task records until October 29 — five months after the first burn and two months after a second burn occurred.
The Director of Nursing said facility staff "including dietary, nursing and management discussed the lid use recommendation during morning report after the incident." But they couldn't explain how this information reached certified nursing aide staff, since the intervention wasn't added to their official tasks until October.
"They were unaware why a portable cup with lid was not put in place after the 04/12/2025 accident," inspectors noted.
Licensed Practical Nurse #15, who responded to the initial burn, said they weren't aware of any interventions put in place afterward to prevent similar incidents. They described current practices where staff monitor for lids during meal service and redirect residents carrying uncovered hot liquids in hallways.
The nurse said they weren't aware of supervision needs for Resident #7, describing the resident as "very independent."
Kitchen staff monitor temperatures of hot fluids delivered to units, according to the Director of Nursing, but unit staff don't check temperatures. The facility uses thick cups for hot beverages with plastic covers "which should be used all the time."
When staff observe residents moving around with uncovered hot liquids, they're supposed to assist by carrying the cup or obtaining a lid. But this system failed to protect Resident #7.
The facility also violated state notification requirements. The Director of Nursing acknowledged that either they or the administrator should have informed the Department of Health about the resident burn. "They stated the Department of Health should have been notified and were unaware why the notification did not occur."
The inspection found residents receive hot fluids with meal trays and can request additional hot beverages from staff throughout the day. But the facility's safety protocols proved inadequate when an independent resident like #7 encountered scalding liquids.
The case illustrates a cascade of institutional failures. First, inadequate immediate safety measures allowed a preventable burn. Then, the absence of required investigation meant nobody examined what went wrong or how to fix it. Finally, a recommended intervention that could have prevented the second burn languished unimplemented for months.
The Director of Nursing's admission that they reviewed the accident report on April 14 but "did not complete a root cause analysis or investigation including the circumstances leading up to Resident #7 being burned or location of where the burn occurred" underscores the facility's failure to take the incident seriously.
Federal regulations require nursing homes to ensure accidents and incidents are thoroughly investigated and that appropriate interventions are implemented to prevent recurrence. Renaissance Rehabilitation's handling of Resident #7's burns violated these basic safety requirements.
The resident suffered a second burn while waiting for safety measures that should have been implemented immediately after the first incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Renaissance Rehabilitation and Nursing Care Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
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