Health inspection·July 16, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few representative. Showed that the facility received new orders and updated Resident#1's care plan. Record review of facility provider investigation report dated 4/23/25 shows that the facility self-reported the incident, notified the resident's physician and received new orders, notified the resident representative, notified the incident to the Texas Health and Human Services Commission and the incident was investigated. The provider investigation report shows that Resident #1 was able to give a statement saying that she accidently burned herself when she spilled coffee into her stomach. Provider investigation report shows that the facility completed in-services regarding hot-liquids and residents at risk for burning themselves. Shows that the residents in the facility who were at risk were specifically named. Shows that staff across all disciplines were in-serviced. Record review of an undated written statement provided to the Administrator from the Social Worker, who first noticed the burn: On the morning of 4/23/25, I entered [Resident #1's] room to gather a box of hospice supplies that were left in her room. Upon entering her room, I noticed her glass of milk had been dropped on the floor and the milk was under her bed. I mentioned it to [Resident #1], and she told me she had spilled her milk and coffee when she tried to pull her overbed table closer to her. She was using her blanket to wipe the coffee off of her. I noticed that she was wiping her stomach with her blanket. I observed some redness to her stomach where the coffee had spilled. I immediately found her nurse and reported it to her, then went back to get some dry blankets on her. Record review of a written statement dated 4/23/25 provided to the Administrator from LVN B, who delivered the breakfast tray to Resident #1 On 4/23/25 at breakfast I [LVN B] TX Nurse delivered [Resident #1's] breakfast tray. [Resident #1] requested coffee. This nurse checked resident's meal tickets and noted no interventions regarding the coffee drinking on meal ticket. Signed by LVN B 4/23/25.During an interview and observation on 7/14/25 at 9:00 a.m., revealed the coffee available for residents to drink was temped using the surveyor's digital probe thermometer. The temperature of the coffee was 116F. The Dietary Manager said that he had brewed coffee that was in the kitchen. The temperature of the coffee inside the kitchen was measured by the investigator at 158F . He said the coffee was inside the kitchen which residents did not have access to but was to be served to residents in the hallways.During an interview on 7/14/25 at 9:33 a.m., Resident #1 was attempted to be interviewed. She was asked about the incident regarding her coffee burn that occurred on the morning 4/23/25. Resident #1 looked at the surveyor but did not respond with an appropriate answer to the question asked. Resident #1 was unintelligible during her interview and did not provide any relevant information. During an observation on 7/14/25 while touring the facility from 9:50 a.m., to 10:10 a.m., multiple residents were observed with lids on their coffee cups. During an observation on 7/14/25 at 12:15 p.m. it was observed that the coffee readily available for resident use in the dining room was measured at approximately 130F using the Dietary Manager's thermometer. The thermometer used by the Dietary Manager was an analog probe thermometer with hashmarks that read at 5-degree intervals. During an observation on 7/14/25 at 1:50 p.m. it was observed that the temperature of the coffee available to residents was 141.9F During an observation on 7/14/25 at 1:28 p.m. with an RN, revealed Resident #1's abdomen was observed. Her abdomen had healed, there was no open wounds, and her skin was clear and intact. Record review in Resident #1's meal ticket for 7/14/25 revealed that the ticked reflected, SPECIAL CUP FOR HER COFFEE WITH A LID During an observation on 7/15/25 at 7:55 a.m. while taking a temperature reading of a cup of coffee made available to residents in the dining room, the temperature of the coffee was 155.3F using a digital probe thermometer. During an interview on 7/15/25 at 9:40 a.m., with the Patient Care Coordinator, she said that Resident #1 ate her meals in her room. She said that a hall cart brought her food and coffee at the same time. She said that Resident #1 should have a lid on her cup of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675386 If continuation sheet Page 2 of 6 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 675386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Pines Lodge 2131 Alpine Rd Longview, TX 75601 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 - Immediate jeopardy to resident health or safety Residents Affected - Few coffee since she was at risk of burning herself. She said that her coffee, since it had a lid, would be poured by the kitchen staff. She said that residents who were not at risk would have a regular open mug, and the coffee would be poured from a thermos that came with the hall cart provided by the kitchen. She said that CNAs and staff passing trays did not take the temperature of the coffee since it was the responsibility of kitchen staff to ensure that the coffee did not exceed the maximum of 140F. She said that no one should take the lid off Resident #1's coffee. During an interview on 7/15/25 at 10:17 a.m., the Director of Nurses said that CNAs or staff passing hall trays do not take the temperature of the coffee as it is passed out. She said that it is the responsibility of dietary staff to ensure the temperature does not exceed 140F. She said that meal tickets included hot liquid restrictions was added after the incident occurred. During an interview on 7/15/25 at 10:23 a.m., Dietary Aide A said that when coffee was served to the halls it would have been served in two different ways. She said that if the resident had a hot liquid risk it would be poured into a cup with a lid on the cup, then placed on the resident's tray . Or it would be poured into a regular coffee mug with no lid directly from a thermos that would be sent out with the hall cart. She said that only the kitchen staff took temperature readings of the coffee. She said that she knew who received a lid or not as they kept an updated list of residents at risk for hot liquids in the kitchen. During an interview on 7/15/25 at 11:00 a.m., the Social Worker said that she was the person who first noticed the burn on Resident #1's stomach. She said that Resident #1 told her that she tried to pull her bedside table closer to herself and when she did, she spilled coffee on the table, the floor, and herself. She said that Resident #1 had a regular coffee mug that came from the kitchen, and it did not have a lid on it. During an interview on 7/16/25 at 9:20 a.m., the Dietary Manager said he expects that his dietary staff follow facility policy regarding hot liquids and coffee. He said that he expected that hot liquids/coffee would not be served at a temperature that exceeds 140F and they are to log what the temperature was. He said that if the temperature exceeded 140F it would not be served until it had cooled down to 140F or below. He said that he expected that residents who require lids for their cups to be in place as it protected those who were at risk of burning themselves. He said that residents could be placed at risk for burning themselves if facility policy was not followed. He said that it was the responsibility of all dietary staff to ensure that residents that require a lid had one in place before the coffee left the kitchen. He said that they have a list of residents who are at risk for spilling hot liquids in the kitchen that is updated regularly. He said that after the incident that occurred on 4/23/25 he was in-serviced on all facility policies regarding residents handling hot liquids, who was at risk, abuse, and neglect. During an interview on 7/16/25 at 9:29 a.m., the Director of Nurses said she expected that staff follow facility policy for hot liquids which would include coffee. She said that staff were to ensure that coffee was served only once it had cooled to 140F or below, staff were taking the accurate temperature of the coffee or hot liquid, residents that required lids have a lid, and that all staff were responsible to ensure that facility policy was followed. She said that residents could be placed at risk for burning themselves if facility policy was not followed. She said that they knew who was at risk because they complete risk assessments for all residents, their care plan was updated if they were at risk, and the individuals at risk were also on their Kardex system. During an interview on 7/16/25 at 9:37 a.m., the Administrator said, she expected that all her staff follow facility policy regarding hot liquids or hot coffee. She said that staff were to take temperature readings of the coffee before it could be served, and it should not exceed 140F. She said that residents should be assessed for risk of handling hot liquids and those at risk of potentially burning themselves should have a lid. She said that all staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675386 If continuation sheet Page 3 of 6 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 675386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Pines Lodge 2131 Alpine Rd Longview, TX 75601 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 - Immediate jeopardy to resident health or safety Residents Affected - Few ultimately responsible for ensuring the policies were followed. She said that residents had the potential to burn themselves if the facility policy was not followed. She said that every resident in the facility is assessed for various risks which included hot liquid assessments. Record review of a facility policy titled, Hot Liquid/Food Spills dated 2003 indicated that, Residents are at risk of having any hot liquid/food spilled on their person causing bums. Examples of hot liquids/food are: coffee, tea, hot soup, oatmeal, or any other hot food or liquid substance.If any staff member observes 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 at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature or cooler liquid directly on the area affected. The charge nurse is to be immediately notified so that an assessment of the resident can be completed. The charge nurse will report any injury to the attending physician and responsible patty and follow any further physician orders. Staff will assist with changing of clothes as needed an incident report and investigation will then be completed and determine if the resident needs further interventions to prevent future occurrences. The Administrator was notified of an IJ on 07/15/25 at 12:09PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 07/15/25 at 5:04 PM and included the following: Whispering Pines Lodge 07/15/25 Plan of Removal Problem : F689 Accidents and Hazards. All residents in the facility that consume coffee were assessed by DON/ADON/Charge Nurse for any signs of injuries from a burn. No coffee burns were assessed. The completion date will be 7/15/25.?? [Resident #1's] hot liquid assessment was completed as of 7/15/25 by the DON.? [Resident #1] was provided with a coffee cup with a lid by the DON as of 7/15/25. [Resident #1's] care plan was updated with the coffee cup as of 7/15/25 by DON.?The resident will be provided with her own personal coffee cup with a lid on 7/15/25. Hot liquid Assessments were updated on all residents that consume coffee in the facility by the DON on 7/15/25.??? Residents at high risk for coffee burns were assessed for the need for assistive devices if consuming hot liquids by the DON/ADON/Regional Compliance Nurse on 7/15/25. Care plans were updated as of 7/15/25 by the DON/ADON/Regional Compliance Nurse. Dietary slips were updated with specialized interventions such as lids, or specialized cups needed for hot liquids 7/15/25 All thermometers in the facility used for coffee temps were replaced with new digital thermometers by the administrator to ensure accuracy. Completed on 7/15/25.?? The administrator, dietary manager, or designee will be responsible daily for ensuring the coffee temperature will be checked and reading within 135-140 degrees [Fahrenheit] and logged prior to serving to residents. Coffee will not be served until the temperature is between 135- 140 degrees. The coffee temps will be logged by dietary staff prior to serving. The dietary manager and administrator will be responsible for ensuring temps are checked and logged daily prior to serving. This process and monitoring will be initiated by the administrator and start 7/15/25 The medical director was notified of the immediate jeopardy on 7/15/25 by the administrator.?? Residents will have access to coffee after it has been verified that the temperature is between 135-140 degrees. The coffee will be placed in the dining room for serving. The Dietary department and Administrator will be responsible for ensuring the temperatures are in range prior to serving. Start date 7/15/25 ? In-services:? ? The ADO will in-service the Administrator and Dietary Manager 1:1 on the following topics on 7/15/25. Completion date will be 7/15/25.? ? Abuse and Neglectserving coffee above 140 degrees could result in neglect and cause injury to a resident.?? All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees. Coffee will not be served at over 140 degrees. All brewed coffee will have the temperature logged before serving by dietary staff or designee.?? Hot liquid Spills Policy- Residents are at high risk for hot liquid spills. This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675386 If continuation sheet Page 4 of 6 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 675386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Pines Lodge 2131 Alpine Rd Longview, TX 75601 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 - Immediate jeopardy to resident health or safety Residents Affected - Few policy explains the procedure following a hot liquid spill on a resident. Guidelines on serving coffee in a nursing facility policy- coffee will be served at temperature between 135- 140 degrees. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability. Following care plans/interventions for residents requiring hot liquid interventions. ? The following in-services were initiated by Administrator, DON, ADON, on 7/15/25 for all staff. Any staff who are not present or in-serviced on 7/15/25, will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced in orientation. All PRN and agency staff will be in-serviced prior to assuming shift. Completion date will be 7/15/25.? ? Abuse and Neglect- serving coffee above 140 degree could result in neglect and cause injury to a resident.?? All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees. Coffee will not be served at over 140 degrees. All brewed coffee will have the temperature logged before serving by dietary staff or designee.?? Hot liquid Spills Policy- Residents are at high risk for hot liquid spills. This policy explains the procedure following a hot liquid spill on a resident Guidelines on serving coffee in a nursing facility policy- coffee will be served at temperature between 135- 140 degrees. Safety precautions may include but are not limited to additional supervision when consuming coffee, insulated or non-insulated coffee mugs with sippy lids, coffee service at lower temperatures, or restricted coffee availability. Following care plans/interventions for residents requiring hot liquid interventions. The surveyor verification of the Plan of Removal from 07/15/25 was as follows:During an observation on 7/16/25 at 7:57 a.m., it was observed that the Dietary Manager was temping the coffee in the kitchen. The dietary manager added ice until the coffee reached 116 Fahrenheit using a digital thermometer. He stated that they were not going to leave coffee out for anyone to get and that residents would need to ask for the coffee to be poured for them by the kitchen staff to ensure that no one received coffee that was too hot to be served. During an observation on 7/16/25 at 8:10 a.m., a walkthrough of the facility was completed and residents who were considered at risk had lids on their coffee cups. Resident #1 was observed with her own cup that had a tight fitting lid that she could drink her coffee from.During an observation on 7/16/25 at 8:15 a.m. Resident #1 was observed using her special cup for coffee with a lid on.Record review of five facility meal tickets with residents who were at risk for handling hot liquids on 7/15/25 at 11:23 a.m., revealed that residents who were at risk for handling hot liquids were notated on their meal ticket and it instructs dietary staff to place a lid on their coffee. During an interview on 7/16/25 at 9:00 a.m. the Dietary Manager stated that they had new digital thermometers so they could have more accurate readings rather than using the analog thermometers with the 5-degree hashmarks. He said that coffee would be given to residents when they asked kitchen staff, and a cup would be poured for them to ensure that no one received a cup of coffee that was over 140F.Record review of an undated AD Hoc (Spontaneous) QAPI Contributors sign in sheet revealed the Administrator, Director of Nurses, Medical Director, Dietary Supervisor, Activity Director. Record review of the facility's assessments of all residents revealed which residents were at risk of spilling hot liquids. Assessments were completed on 7/15/2025 by the DON and care plans were updated to reflect their risk for hot liquids.Record review of Resident #1's meal ticket dated 7/14/25 revealed that her ticket stated, SPECIAL CUP FOR COFFEE!!!! SPECIAL CUP FOR HER COFFEE REQUIRES LIDDuring interviews from 7/14/25 at 12:38 p.m. to 7/16/25 8:29 a.m. the following staff were interviewed: the Social Worker, Director of Nurses, Administrator, Assistant Director of Nurses, Dietary Manager, MDS Coordinator, Patient Care Coordinator, Activity Director, Dietary Aide A, LVN B, CNA C, LVN D, CMA E, Dietary Aide F, Dietary Aide G, CMA H, CNA I, Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675386 If continuation sheet Page 5 of 6 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 675386 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Pines Lodge 2131 Alpine Rd Longview, TX 75601 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Aide J, CMA K, LVN L, LVN M, LVN N, CNA O, RN P, CNA Q, LVN R, Dietary Aide S, Dietary Aide T, Certified Occupational Therapist U, Dietary Aide V The staff interviewed worked across various shifts including days, evenings, and nights. All staff said they were in-serviced on the Hot liquid Spills Policy, Guidelines on serving coffee in a nursing facility policy, and Abuse and Neglect. The dietary staff were able to articulate that coffee should not exceed 140F, to cool coffee down by using ice until it was below the 140F threshold. The dietary staff were in-serviced that dietary slips would notate if a resident was at risk for spilling hot liquids, abuse and neglect, and to log the temperature of coffee when it was made available to be given to residents. All other staff were able to articulate their in-service training on abuse and neglect and who to report to if they found that a resident had a burn, that 140F was the maximum temperature coffee could be served at, at risk residents needed a lid on their coffee, where to find which resident was at risk, and that each residents meal ticket would indicate if they had a special intervention for hot liquids. On 07/16/25 at 08:47AM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Event ID: Facility ID: 675386 If continuation sheet Page 6 of 6