Buckeye Care and Rehabilitation: Coffee Burn Violation - OH
The resident, identified in inspection records only as Resident 76, was using the cup his occupational therapist had recommended, a two-handled cup with a spouted lid, designed to reduce exactly this kind of spill. He used it as ordered. He spilled anyway.
On February 20, a nurse examined him after staff brought him back from the dining area. He would not let anyone remove his pants to look at the area where the coffee had landed. The nurse documented a blister on his right outer leg with some redness. The facility notified his physician and a family member. The immediate response was to switch him to a restrictive flow cup for hot liquids going forward.
Two days later, the facility's interdisciplinary team met to review the incident. Their note reflected a conclusion that might have seemed reassuring at the time: all safety interventions had been in place and functional when the spill occurred. The plan of care was current. The cup had handles and a lid. Everything had been done right.
Then came the wound evaluation on February 24.
Four days after the incident, a clinician assessed a second-degree burn on Resident 76's right thigh. It measured 10.5 centimeters long by 6.6 centimeters wide, roughly the size of a deck of playing cards pressed flat against his skin. No signs of infection were present, and no pain response was noted, which, in a resident with his level of cognitive impairment, is not necessarily reassuring.
The burn took until April 7 to resolve. That is 46 days from the spill to closure, nearly seven weeks for a wound that began as a lunch accident.
Federal inspectors visited Buckeye Care on August 19 as part of a complaint investigation and interviewed the facility's Assistant Director of Nursing. She confirmed the sequence: the occupational therapy recommendation, the cup in use at the time of the spill, the burn diagnosis four days later, the treatment orders, the eventual resolution without infection or complication. She also confirmed that the restrictive flow cup was implemented after the incident as an additional precaution.
The inspection report cited the facility for failing to ensure residents remained free from burns. The deficiency was tagged at a level of minimal harm or potential for actual harm. One resident out of three reviewed for accidents was affected. The facility census at the time of the inspection was 93 residents.
What the records do not resolve is the gap between February 20 and February 24. The blister was visible the night of the spill. The nurse documented it. The interdisciplinary team met two days later and updated the plan of care. The second-degree burn diagnosis came the day after that meeting. Whether the wound was assessed as a second-degree burn earlier and not documented that way, or whether the full extent of the injury was not recognized until the formal wound evaluation four days in, the inspection report does not say.
Resident 76 had impaired cognition documented in his most recent assessment. He had Parkinsonism, which affects motor control, and dysphagia, which affects swallowing. He was using adaptive equipment. He still ended up with a burn that took a month and a half to heal.
The facility added a restrictive flow cup after the incident. The wound closed without infection. By the metrics that appear in the record, the outcome was as good as it could have been once the burn occurred.
What it took to get there was 46 days of wound care for a man who could not fully communicate what he was feeling, in a leg he would not let anyone examine on the day it happened.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
BUCKEYE CARE AND REHABILITATION in LANCASTER, OH was cited for violations during a health inspection on August 19, 2025.
On February 20, a nurse examined him after staff brought him back from the dining area.
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.