Inspection·July 3, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Interview conducted on 07/03/2024 at 10:32 AM with DM revealed that the temperature of the coffee should be 140 degrees. She stated that a thermometer has been used to check the temperatures of the coffee. The temperature of the coffee is checked before leaving the kitchen. She stated a potential negative outcome of providing coffee too hot, above 140 degrees to the residents is the residents could get severe burns. Residents Affected - Few Interview conducted on 07/03/2024 at 10:40 AM with DON revealed that the expectation for the coffee was to be measured before being served. She stated that it should be 140 degrees. If the coffee is hotter than 140 degrees, it is not allowed out of the kitchen until the temperature is down. DON stated a potential negative outcome of serving coffee that is too hot for residents, is that the residents could burn themselves. Interview conducted on 07/03/2024 at 11:04 AM with LVN A revealed that Resident #3 had spilled coffee on herself in the past. She stated that she had went and tried to get the by coffee herself and ended up spilling it on her legs. She had redness burns that were treated by staff with cold compress and scheduled pain medication. She stated that a potential negative outcome of coffee being too hot for residents is getting burned. Interview conducted on 07/03/2024 at 11:23 AM with LVN B revealed that Resident #3 had spilled coffee on herself one time. She stated that because of this, the facility checks the coffee temperature to ensure that it is under 140 degrees. She stated that the residents are upset because the coffee is not hot like they like it. She stated a potential negative outcome of coffee being too hot for residents is that they can get burned really bad and have to perform treatments on them. Interview conducted on 07/03/2024 at 11:47 AM with LVN C revealed that Resident #3 is only able to use one arm, had gotten her own coffee and was wheeling out of the dining room when it spilled on herself. She stated that Resident #3 had burns on her legs. She stated a potential negative outcome of coffee being too hot for residents is burns are a possibility. Observation on 07/03/2024 at 12:30 PM revealed that the coffee was at a temperature able to consume without pain or caution of burning when a food tray was sampled with a cup of coffee and tasted. Interview conducted on 07/03/2024 at 02:14 PM with ADM revealed that the expectation for temperatures of coffee is to be 140 degrees when it leaves the kitchen. He stated that Resident #3 had gotten a cup of coffee and it had spilled on her. The accident was observed by staff members. He stated that resident is often persistent on being independent and refuses help, which is what happened at that time. He stated that the resident had no complaints of pain, no burns at the time and was provided treatment and care immediately afterward. He stated that the facility had provided the resident with an ice pack in which they monitored the redness closely. He stated that the resident was getting coffee for someone else and spilled the coffee on her lap when she was wheeling away in her wheelchair. He stated that in-services were provided immediately after the incident and all staff were aware of the coffee needing to be maintained at 140 degrees before being served. He stated if the coffee was above 140 degrees the staff will cool it down and take it out of the lobby, so it is not served to the residents. He stated that the facility has staff in the dining room watching the coffee area when residents are and are not present to provide support as necessary. They also heavily encourage the residents to ask staff for the coffee or the staff try to be proactive in providing the coffee to the residents before any accidents could occur. ADM stated that a negative outcome of providing coffee that is too hot to residents is a burn could happen, depending on where it lands and how long it sits on the skin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 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 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 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 Record review of in-services revealed that in-services were completed for Hot liquid/Food Spills liquids must be at 140 degrees or below if served to a resident. This document was dated 03/10/2024 and was signed by staff. Record review of undated document provided by the facility called Guidelines to Serving Coffee in the nursing home on [DATE] at 1:00 PM revealed the following. -As there is no published federal or state regulation for minimum or maximum coffee temperature, the decision as to the temperature at which to serve the coffee rests with the administration of each facility, based on their resident's stated preferences, and the physical layout of their building, but balanced against the safety of their individual residents and their physical and mental limitations. - The standard for coffee service will be 140 degrees unless the facility's residents have stated an overwhelming preference for coffee to be served at a higher temperature and additional safety measures have been implemented. Record review of Hot Liquid/Food Spills document dated 2003 revealed that if residents are at risk of having any hot liquid food/spilled on their person causing burns the following actions should occur. Examples of hot liquids/foods are coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance. It stated if any staff member observed a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with a liquid that is at room temperature or below, by pouring the liquid directly on the area affected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 3 of 3