Inspection·December 23, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment. The same MDS indicated resident required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs, or other non-weight-bearing assistance) with eating. Record review of a Hot Liquid assessment dated [DATE] and completed by the DON, indicated Resident #1 was not able to hold hot liquids in a cup or bowl without difficulty, had tremors to upper body area, needed assistance with eating, and tremors were worse some days more than others. The interventions section of the Hot Liquid Assessment indicated Resident #1 was safe to drink hot liquids without assistance using a cup with a lid. The latter part of this section indicated resident required assistance while drinking hot liquids from a cup with a lid. Record review of a care plan initiated on 02/24/2022 indicated Resident #1 required set-up help, supervision, verbal cueing, and physical assistance as needed with eating. The care plan did not include any directions for a cup with lid (sippy cup) for hot liquids. Record review of nurses' notes written by LVN E and dated 12/12/2023 at 11:54 AM indicated the Hospice Chaplain gave Resident #1 a cup of coffee and a few minutes later, Resident #1 spilled the coffee onto her left leg. The notes indicated facility staff responded immediately, took Resident #1 to her room, removed her pants, and applied cool compress to the left thigh. The area was described as a red streak down the left thigh with no blistering and no reported pain. Review of nurses' notes written by LVN C and dated 12/13/2023 at 08:34 AM indicated a description of the left thigh as having a pale pink, thin line with no blistering and no reported pain. A record review of the Hospice Notebook for Resident #1 did not indicate a care plan nor any instructions in regard to Resident #1's care. There was no indication of Resident #1's need for supervision nor a cup with a lid for drinking hot liquids. During an interview with Non-Certified Aide A on 12/23/2023 at 08:20 AM, she said the staff knew who to give cups with lids to because it was on the residents' meal tray tickets. Aide A said coffee comes out in a carafe with the meal trays and the staff delivering the trays refer to the meal ticket for instructions on preferred drinks and assistive devices. She said the facility used sippy cups (a 2-handled cup with a lid that has a spout to sip from)) for residents who were at risk to spill their drinks. She did not know how hospice staff or visitors would know if a resident required assistive devices for drinking coffee. During an interview with Non-certified Aide B at 08:35 AM, she said the meal tickets come out with the trays. She said the meal tickets tell the staff what the resident is supposed to have with their meals. She said Resident #1 did not need anything special to drink her coffee but since she spilled coffee on herself a couple of weeks ago, someone watches her when she is drinking coffee. During observation and interview on 12/23/2023 at 09:30 AM, LVN C, was observed to assist Resident #1 to turn toward her ride side to expose the resident's left thigh. LVN C pointed to the area where coffee spilled onto the resident's thigh. No evidence of a burn, red, or open areas were noted. A faint, light tan line approximately 3.0x0.3 cm was noted to the left, lateral distal thigh. Resident denied any pain when area was touched by LVN C. LVN C said the area had not required any treatment nor had Resident #1 required any pain medication because of the coffee spill. During an interview with LVN C on 12/23/2023 at 09:40 AM, she said hospice staff use electronic devices to refer to for resident care information. She said as far as she knew, the facility nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455856 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Van Healthcare 169 S Oak St Van, TX 75790 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff did not have access to the information on those devices. She said the information the facility had was in individual notebooks at the nurses' station. During an interview with the DON and ADON on 12/23/2023 at 09:50 AM, the DON said hospice staff had not been told Resident #1 required specific devices for drinking coffee because a Hot Liquid Assessment completed on 11/19/2023 indicated Resident #1 could manage hot liquids without any assistive devices. The DON said there were no residents who used lids on their cups. During an interview with the DM on 12/23/2023 at 10:00 AM, she said she was responsible for ensuring meal tickets included information specific to each resident including any assistive devices to be used. She said she was not aware that Resident #1 required any assistive devices. The DM said the facility did not have any lids for the coffee cups. She said the facility had sippy cups for residents who are at risk for spilling hot liquids. During an interview with ADM on 12/23/2023 at 11:00 AM, she said the facility does not use lids for their coffee cups. During a phone interview with Hospice Chaplain D on 12/23/2023 at 11:11 AM, she said that on 12/12/2023, she wheeled Resident #1 to a table in the dining room and gave her a half cup of coffee because she knew the resident's hands shook some. She said she went to visit another resident in the dining room and after about 10 minutes, she looked over at Resident #1 and saw her push herself away from the table, pick her coffee cup up from her lap and throw it to the floor. She said she went to Resident #1, saw that she had spilled her coffee, lifted the pant leg away from the thigh, and held it while she called for help. She said the pants did not feel hot and the resident denied any pain. She said she was not aware Resident #1 was to have a lid on her coffee cup. During a phone interview on 12/23/2023 at 11:28 AM with LVN E, she said the Medication Aide made her aware that Resident #1 had spilled her coffee onto her leg. She said she and the medication aide took Resident #1 to her room, removed her pants, and saw a pink, non-blistering line down her left lateral thigh. She said she applied a cold compress to the area and notified the nurse practioner, Hospice Nurse on call, and the family. During an interview with DON on 12/23/2023 at 1:44 PM, he said hospice staff are invited to the care plan meetings but do not always come. He said the 11/19/2023 Hot Liquid Assessment that indicated Resident #1 was capable of handling hot liquids in a cup was correct. He said the 11/29/2023 Hot Liquid Assessment that indicated Resident #1 was to have a cup with a lid and supervision when drinking hot liquids was incorrect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455856 If continuation sheet Page 3 of 3