A senior living community hit with a $1.8 million civil monetary penalty over what attorneys call a made-up safety violation is still waiting for its day in court—nearly eight years after the original citation.

Eight years? Yikes.

The case began when a surveyor observed coffee being served and judged it “overly hot.” A record review followed, identifying a resident who had previously sustained minor injuries after being served hot coffee by a private duty aide. The result? The building was cited for Immediate Jeopardy and fined $6,550 per day—272 days in total—for “non-compliant” coffee temperatures.

This isn’t an isolated case. According to attorneys who handle these types of appeals, it’s one of dozens currently stalled at the Department of Health and Human Services Appeals Board. The DAB is the final judicial body within HHS before a provider can take a case to federal court. Last year alone, the DAB decided just 39 cases, and only six involved senior living communities, as noted in the official 2024 HHS Board Decisions.

McKnight’s Long-Term Care News has been following this debacle for years, emphasizing in a related piece that justice delayed is justice denied—especially in skilled nursing. And sadly, there’s no end in sight.

So, here’s the takeaway: When was the last time your community checked point-of-service hot liquid temperatures? Do you know which residents are most at risk for burns? Is anything being done right now to reduce that risk?

Please take time to bring this discussion to your QAPI committee. Use a formalized process to identify residents at risk of injury. Resources like Hot Liquids (5).pdf , Hot Liquids Risk Screening (4).pdf and Hot Liquids Handling Protocol provide assessment tools that can help.

Educate your dietary department on documenting hot liquid temperatures at the point of service. Use clothing protectors as needed. Involve your therapy department in observing meal service and identifying residents who may need extra support.

Because here’s the hard truth: IT CAN HAPPEN TO YOU.

Stay well and stay informed.