Buckeye Care: Coffee Burn Leaves 4-Inch Wound - OH
The February incident at Buckeye Care and Rehabilitation involved Resident 76, who had been assessed by occupational therapy before the burn and was already using a two-handled cup with a spouted lid specifically recommended to prevent spillage and burns while consuming liquids.
The resident spilled coffee on himself in the dining area on February 20. When staff brought him back to his room, he refused to let them remove his pants to assess where the coffee had spilled. A nurse completed a head-to-toe assessment and discovered a blister on his right outer leg with redness.
Four days later, facility staff measured the wound during a formal skin evaluation. The second-degree burn stretched 10.5 centimeters long by 6.6 centimeters wide — roughly four inches by two and a half inches. No pain was assessed, and no signs of infection were noted.
The resident had multiple conditions that complicated his care. His diagnoses included Parkinsonism, dementia, and dysphagia, a swallowing disorder. A July assessment found he had impaired cognition.
Assistant Director of Nursing 263 confirmed during an August interview with state inspectors that occupational therapy had evaluated the resident before the incident. The therapists recommended the two-handled cup with spouted lid that he was using when the burn occurred.
"The resident was using the cup as ordered at the time of the incident," the nursing director told inspectors.
After the burn, facility staff implemented additional safety measures. They switched the resident to restrictive flow cups for all hot liquids, not just the specialized cup he had been using. The new cups further limited how quickly hot liquids could pour out.
The facility's interdisciplinary team met two days after the incident to review what happened. Team members concluded that all aspects of the resident's care plan had been in place at the time of the burn. All safety interventions were functioning properly when the coffee spilled.
The team noted in their February 22 meeting that the resident's liquids were already in a lidded cup with handles when the accident occurred — exactly what occupational therapy had prescribed to prevent burns.
Treatment orders for the burn were obtained and implemented immediately after the incident. The physician and the resident's responsible party were both notified about the wound and the new safety intervention.
The burn took nearly seven weeks to heal completely. The nursing director confirmed the wound resolved without infection or complications on April 7, more than six weeks after the initial spill.
Federal inspectors cited the facility for failing to ensure residents remained free from burns, finding minimal harm or potential for actual harm to few residents. The violation affected one resident out of three reviewed for accidents during the inspection.
Buckeye Care and Rehabilitation had 93 residents at the time of the August inspection, which was conducted in response to a complaint. The facility violated federal requirements that nursing homes maintain environments free from accident hazards and provide adequate supervision to prevent accidents.
The case illustrates the challenges nursing homes face in preventing accidents among residents with cognitive impairments and movement disorders. Despite following occupational therapy recommendations and using prescribed safety equipment, the resident still sustained a significant burn that required weeks of treatment.
The resident's refusal to allow staff to remove his clothing immediately after the spill may have delayed the discovery of the full extent of his injury. His cognitive impairment, documented in facility assessments, likely contributed to his resistance to staff assistance.
State inspectors documented the incident as part of complaint investigation number 1386024. The inspection occurred six months after the burn incident, suggesting the complaint may have been filed by family members or others concerned about the facility's accident prevention measures.
The restrictive flow cups implemented after the February burn remained in place for all hot liquids served to the resident, according to the nursing director's interview with inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Buckeye Care and Rehabilitation from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Buckeye Care and Rehabilitation
- Browse all OH nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
BUCKEYE CARE AND REHABILITATION in LANCASTER, OH was cited for violations during a health inspection on August 19, 2025.
The resident spilled coffee on himself in the dining area on February 20.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at BUCKEYE CARE AND REHABILITATION?
- The resident spilled coffee on himself in the dining area on February 20.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in LANCASTER, OH, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from BUCKEYE CARE AND REHABILITATION or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 365250.
- Has this facility had violations before?
- To check BUCKEYE CARE AND REHABILITATION's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.