Greentree of Hubbell: Hot Coffee Burns Resident - MI]
The aide, identified in inspection records only as CNA J, knew the coffee was too hot when the kitchen handed it to her. She went to get ice cubes and a lid. She added the ice cubes. Then another resident called out for something, and she set the cup down in front of the woman without the lid.
Staff only realized what had happened when someone noticed the resident was wet. She had just been changed before breakfast. When they brought her back to her room, they found redness across her breast and right stomach. The redness extended down to her upper legs. Her left thigh had blistered.
The resident's care plan had required a two-handled cup with a lid for coffee since March 28, 2025, nearly six months before the burn. The plan noted she had a nutritional problem or potential nutritional problem and that she liked coffee black with every meal. The lid requirement was written down. It was part of her record.
Federal inspectors rated the violation as causing actual harm.
CNA J did not deny what happened. In a phone interview with inspectors on September 16, the day of the inspection, she described the morning in plain terms. The facility was short-staffed. She was running around trying to get everyone set up for breakfast. She knew the coffee was too hot. She took the step of getting ice. She was on her way back for the lid when she was interrupted.
"I take full responsibility for that mistake," she told inspectors. "I have no problem admitting I made a mistake. I made the mistake because we don't have enough staff to manage that many residents on our daily assignments, and remember everything, it is impossible to do that under the conditions we are working. I am so sorry. I feel absolute horrible."
The burn happened on or around September 12, 2025. An interdisciplinary team note from that morning, timestamped 9:39 a.m., documented that staff had reviewed the incident and that a two-handled spout cup with lid for coffee had been implemented. A message sent three minutes earlier, at 9:38 a.m., showed the assistant director of nursing asking whether they could get an order for that cup.
The lidded cup became official policy the morning the resident was burned. It had been in her care plan for months.
Greentree of Hubbell sits on B Avenue in Hubbell, a small copper country town in Michigan's Upper Peninsula. The facility's provider number is 235551. The complaint inspection was completed September 16, 2025.
What CNA J described, a single aide responsible for enough residents that tracking individual care requirements becomes impossible, is not a problem inspectors can fix with a corrective order. The lidded cup is now in place. The staffing level that made the aide forget it is not something that shows up in a plan of correction.
The resident went into breakfast that morning the way she had many mornings, seated at the dining room table, waiting for her coffee. The aide who brought it to her knew it was too hot and knew it needed a lid. She was trying to do both things at once, for more residents than she could manage, and she couldn't.
The blistering was on the left thigh.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greentree of Hubbell Rehabilitation and Health from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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 28, 2026 · Our methodology
Greentree of Hubbell Rehabilitation and Health in Hubbell, MI was cited for violations during a health inspection on September 16, 2025.
The aide, identified in inspection records only as CNA J, knew the coffee was too hot when the kitchen handed it to her.
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.