Health inspection·August 28, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's physician following an incident that occurred on 08/09/2025 at 4:30PM in the Dining Room, when Resident #4 was attempting to get a cup of coffee. The cup overflowed and spilled coffee in Resident #4s lap, resulting in Resident #4 sustaining 3 blisters to the left upper thigh. The facility failed to notify Resident #4's physician when he sustained burns from hot coffee, he spilled in his lap. This deficient practice could place residents at risk of not receiving adequate and timely intervention. The findings include: Record review of Resident #4's undated Face Sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, unspecified (brain tissue death caused by a blocked artery supplying blood to the brain, leading to a lack of oxygen and nutrients) and Hemiplegia (the total or severe loss of motor function on one side of the body, resulting in paralysis) and Hemiparesis (weakness on one side of the body, affecting the arm, leg, or face) following cerebral infarction affecting right dominant side. Record review of Resident #4's quarterly MDS, dated [DATE] reflected a BIMS score of 12 (moderate cognitive impairment) and in Section G, the need for a low level of supervision in the form of staff oversight, with encouragement or cueing with eating or drinking. Record review of Resident #4's Care Plan, last updated 08/18/2025 reflected that Resident #4 requires some minimal assistance with ADLs, and he does not ask for help and often time refuses to allow staff to help him, History of CVA with right hemiparesis, Current. Care Planned interventions include the following:Approach: Eating: Assist of 1 staff member. Record Review was conducted of Resident #4's medical record. A progress note entered by LVN D on 08/09/2025 at 6:30PM, described how Resident #4 spilled coffee in his lap and LVN Ds assessment of Resident #4 who denied any injury. There was no documentation of notification of the physician or the DON in the progress note. During an interview with DA C conducted on 08/20/2025 at 2:38PM, she stated she saw Resident #4 trying to get coffee and she tried to help. DA C stated there was a lid on the cup, but it spilled anyway, and DA C reported the event immediately to the nurse. During an interview with the DON on 08/20/2025 at 4:45PM, the DON stated she was not notified of the event until the following day. She stated had she been notified; she would have ensured Resident #4's physician was notified. The DON stated she implemented corrective action with LVN D for not notifying the physician and the DON. Record review of the facility investigation report dated 08/15/2025 was performed on 08/20/2025. The report indicated the facility investigation findings as unconfirmed. There is also documentation of the following: Nursing Staff in services on Abuse, Neglect/Misappropriation, Hot Beverage Policy, Burn Policy and Proper Notification to the DON and Administrator, The Administrator, DON, and Dietary Manager were in serviced on Guidelines to Reduce the Risk of Burns from Hot Beverages, Dietary staff were in serviced on measuring the temperature of coffee and placing a sticker on the coffee pots with the date and temperature of the coffee, and One on one Page 1 of 10 676409 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Inservice with LVN D regarding reporting incident/change of condition to the DON/Designee. Documentation of the Personnel action was present and reflected the signature of LVN D. Record Review of in-service dated 08/11/2025 reflected 20 staff had been in-serviced on notification of resident change. Our ability to ensure trust is paramount in what we do daily, and by keeping lines of communication open and involving the resident and their responsible party/emergency contact in the care we are providing; we build that foundation. It is REQUIRED to notify residents, responsible parties, or an emergency contact of any changes that occur with our residents. Responsible Party (RP) or an emergency contact if resident is their own RP will be notified of any changes at the time of occurrence and be DOCUMENTED in the progress notes.Record Review of in-service dated 08/11/2025 reflected 14 staff had been in-serviced on notification to the director of nursing but there was no mention of notification of the physician. Communication is crucial for proper management of nursing facilities and notification of the Director of nursing is imperative. You are required to notify the Director of Nursing and or designee for the following immediately: Incidents and Accidents with C/O Pain or Observed Injury BurnsSafety Hazards / Equipment Malfunction Record Review of in-service dated 08/12/2025 reflected 22 staff had been in-serviced on burns. Burns are a major incident in nursing homes and can cause serious negative out comes. Any burn injuries are required to have the provider assigned, DON, RP, and administrator notified immediately no matter the severity of the burn. Record Review of facility wound care policies and procedures revision date 06/01/2015 reflected all burns and scalds will be seen by a physician or a nurse as soon as possible for appropriate treatment. The purpose is to provide immediate first aid when injury occurs in the facility. Record review of the policy entitled: Care of a Burn Injury dated 06/01/2025 states Notify the physician and supervisor as soon as possible. 676409 Page 2 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #4) reviewed for accidents, hazards, and supervision, in that: The facility failed to provide adequate supervision to prevent injury for an incident that occurred on on 08/09/2025 at 4:30PM in the Dining Room, Resident #4 was attempting to get a cup of coffee. The cup overflowed and spilled coffee in Resident #4's lap and resulted in urns with 3 blisters to the left upper thigh. The facility failed to take the temperature of the coffee and keep temperature logs of the coffee. The facility failed to assess other residents for hot liquids An (IJ) Immediate Jeopardy was identified on 08/26/2025. The IJ template was provided to the ADM on 08/26/2025 at 7:28PM. While the IJ was removed on 8/28/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the 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. Findings included: Record review of Resident #4's undated Face Sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, unspecified (brain tissue death caused by a blocked artery supplying blood to the brain, leading to a lack of oxygen and nutrients) and Hemiplegia (the total or severe loss of motor function on one side of the body, resulting in paralysis) and Hemiparesis (weakness on one side of the body, affecting the arm, leg, or face) following cerebral infarction affecting right dominant side, diabetes, Hypertension, Burn of unspecified degree of left thigh Record review of Resident #4's quarterly MDS, dated [DATE] reflected a BIMS score of 12 (moderate cognitive impairment) Section G of the MDS reflected for eating and drinking resident# 4 required the need for supervision, oversight, encouragement and cueing. Record review of Resident #4's Care Plan, last updated 08/18/2025 reflected that Resident #4 required some minimal assistance with ADLs. History of CVA with right hemiparesis, Current. Care Planned interventions include the following: Approach: Eating: Assist of 1 staff member.During an interview with DA C conducted on 08/20/2025 at 2:38PM, she stated she saw Resident #4 trying to get coffee and she tried to help. DA C stated there was a lid on the cup, but it spilled anyway, and DA C reported the event immediately to the nurse. During the verbal assessment performed by the nurse, Resident #4 denied any injury. DA C stated she was in-serviced on removing the coffee servers from the Dining Room and placing them in the locked Nutrition Room after each meal service and the dietary staff are not to bring the coffee into the Dining Room unless nursing staff are present. On 08/20/2025 at 2:42PM, conducted a phone interview with the Dietary Manager. The Dietary Manager confirmed the coffee available for self-service to the residents prior to Resident #4 receiving the burn injury was not temperature tested. On 08/20/2025 at 3:13PM conducted an interview with LVN E. She stated Resident #4 informed her about the burns to his legs on the day following the event. LVN E stated she assessed the leg on 08/10/2025 at 7:27AM and obtained orders for care of the wounds and notified the DON. She stated she did find 3 open areas that appeared to be blisters that had burst. Record review of Resident #4's progress note dated 08/09/25 at 6:30 PM Recorded as Late Entry on 08/12/2025 at 08:53 AM- reflected Resident found in dining room with pants wet with coffee. Resident assessed for pain and burn. Resident reported not feeling pain or burn. Resident reported I'm fine I don't feel burn right now. Resident continued with process of getting coffee and returned to room. Record Review on 8/20/2025 of the progress note dated 08/09/2025 at 6:30PM written by LVN D regarding the coffee spill. LVN D documented that she asked the resident if he was 676409 Page 3 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few injured, and Resident #4 denied being injured. Record review of Resident #4's incident report dated 08/10/25 reflected incident date 08/09/2025 resident was observed in the dining room with pants wet with coffee. Resident reported trying to get coffee with kitchen staff assistance. Resident assessed immediately for pain and burn. Resident reported not feeling pain or burn stating I'm fine I don't feel any pain. Resident proceeded with getting another cup of coffee and returning to his room.Record review of Resident #4's progress note dated 08/10/25 at 6:00 PM [Recorded as Late Entry on 08/12/2025 at 08:51 AM] reflected Resident reported dressing came off. Assessed skin and affected area. Skin appears pink and moist. Changed dressing. Resident reported feeling pain during procedure. Resident was given PRN acetaminophen. Cleaned skin with normal saline and gauze. Xeroform Petrolatum dressing placed on affected area. Covered dressing with Non adhesive super absorbent wound dressing and secured with skin tape. Assessed resident for discomfort. Resident tolerated procedure with no further discomfort after receiving PRN pain medication. Record review of Resident #4's prescription orders dated 08/10/25 reflected order description: for Silvadene (silver sulfadiazine) cream; 1%; amt: small amount cover wounds; topical, frequency: twice a day 1: 06:00 AM- 06:00 PM 2: 06:00 AM- 06:00 PM. Special instructions: apply cream to 3 open wounds on left thigh.Record review of Resident #4's progress note dated 08/10/25 at 11:30 AM -- INVALID -- On 8/9/25, at 6:30PM, reflected resident was found in dining room with pants wet with coffee spilled on himself. Resident assessed for pain and burn. Resident reported not feeling pain or burn. resident returned to room with coffee. Record review of Resident #4's progress note dated 08/10/25 at 11:25 AM -- INVALID-- reflected Resident found in dining room with pants wet with coffee. Resident assessed for pain and burn. Resident reported not feeling pain or burn. Resident reported I'm fine I don't feel burn right now. Resident continued with process of getting coffee and returned to room. Record review of Resident #4's progress note dated 08/10/25 at 9:45 AM reflected Call made to resident's family member to inform about coffee spilling on resident's left thigh. Discussed treatment plan ordered by provider. Advised that will continue to monitor resident for any signs of infection. Answered all questions and listened to concerns had. Family member stated that she will be at facility later today to see resident. Record review of Resident #4's progress note dated 08/10/25 at 9:32 AM reflected Call to on-call provider to notify that resident had coffee spilled onto left thigh. Rec'd order for Silvadene cream to be applied to areas 2x per day. Wound care order to cleanse area with normal saline, apply thick layer of Silvadene cream and to cover with non-stick dressing and monitor for sign/symptoms of infection. Record review of Resident #4's progress note dated 08/10/25 at 8:23 AM reflected Spoke with resident about coffee spill incident that occurred on Saturday evening. Resident stated that after dinner the dietary aide helped him get coffee while in the dining room. Resident was using the cup with the lid, but it must have been overfilled. Stated that the coffee spilled onto his leg. He stated the dietary aide put towels on the area and took him to his room. Resident reports that it was not painful. Assessed left thigh and observed approximately dollar size open area, quarter sized open area, and dime size area open area. No signs/symptoms of infection noted. Will continue to monitor for changes. Record review of Resident #4's progress note dated 08/10/25 at 7:27 AM reflected Resident came up to this nurse and stated he was in the dining room getting coffee with another resident yesterday and they spilled coffee on his lap. Resident L thigh has 3 open areas where it appears to have bubbled then burst. Area cleaned and dressing placed. Weekend supervisor and DON notified. Record review of a therapy screening form dated 08/11/25 for Resident #4 reflected nursing referral for difficulty performing ADLs: feeding. Resident with coffee burn, assessment of AE referral, occupational therapy is recommended. Record review of Resident #4's progress note dated 08/11/25 at 1:22 PM reflected Resident seen by 676409 Page 4 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few provider due to recent burns to left thigh. New orders received to start Doxycycline 100mg BID x10 days to prevent infection. Orders updated on MAR; family member aware. No other concerns at this time. Care ongoing.Record review of Resident #4's progress note dated 08/13/25 at 1:21 PM reflected Resident seen for initial visit by Dr. for Burn Wound of Left, Anterior Thigh w/Partial Thickness and Burn Wound of Left Medial Thigh w/Partial Thickness. Burn wound #1 is located on left anterior thigh caused by hot beverage; wound measures 6.1 x 4.5 x 0.1 cm/surface area 27.45 cm2. Light serous drainage (clear, watery fluid) noted. 100% dermis observed. Edges attached to wound base. Redness noted to peri-wound. Temperature is warm to touch. Burn wound #2 is located on the left medial thigh; measuring 2.3 x 13 x 0.21 cm/surface area 29.90 cm2. Light serous drainage noted. Erythema (superficial reddening of the skin)and fluid filled blisters noted to peri wound. Edges attached to base. 100% Dermis observed. New orders apply Silver Sulfadiazine to wounds, cover with Xeroform Gauze dressing, and wrap wounds with Gauze Roll Kerlix 4'5, and secure Kerlix with Ace Bandage or Coban 3(three) times daily. Emergency contact updated on wound visit with WCD. No concerns verbalized at this time.On 8/20/2025 at 11:15am attempted observation and interview with resident# 4, not available not in room. Attempted to locate resident # 4 throughout the day. On 08/20/2025 at 4:45PM conducted an in-person interview with the DON. The DON stated she was not notified that the resident sustained burns to his upper leg on the evening it occurred. She was notified on 8/10/2025 by the Nursing Supervisor, LVN E, after Resident #4 had complained to her that morning about having the burns on his leg. The DON stated she notified her corporate supervisor as soon as she was notified of the event. The DON then described the follow up actions of both nurses to include they received instructions for wound care. The DON also verbally confirmed the documented in-service training received by herself, the Administrator, and the Dietary Director. The DON further stated she initiated in-service training with the staff immediately. The DON stated she was not notified of the event in a timely manner; therefore, she implemented corrective action with the responsible nurse. In an interview on 8/26/2025 with the DON at 4:00pm revealed they completed an observation assessment on 8/10/2025 and 8/18/2025. The DON stated each resident who had access and drank coffee was observed this included 19 other residents. The DON stated they did not have a formal assessment for the observation that was completed. The DON was not able to state what the observation included in order to determine if a referral to PT (physical therapy) was needed. The DON stated the results of the observations completed was not documented. Record Review of the policy Guidelines to Reduce Risk of Burns from Hot Beverages. Dated 08/01/2020. The policy statement stated, Precautions shall be implemented to limit the risk of burns from hot beverages (coffee, tea, etc.). he policy described the recommended coffee brewing temperatures as between 195- and 205-degrees Fahrenheit. The actual serving temperatures should range from 155 degrees to 175 degrees based on individual preference. An (IJ) Immediate Jeopardy was identified on 08/26/2025 at 7:15PM due to the above failures. The Census was 64. The ADM was notified on 08/26/2025 at 7:28PM. The ADM was provided with the (IJ) Immediate Jeopardy template on 08/26/2025 at 7:28PM, and a Plan of Removal (POR) was requested. A Plan of Removal was first submitted by the ADM on 08/26/2025 at 9:20PM. The Plan of Removal was accepted on 08/28/2025 at 3:43PM. The facility failed to ensure that the resident environment remained free from accidents and was appropriately supervised. Performed Record Review of facility investigation and follow up of the incident on 08/20/2025. Charge Nurse verbally questioned resident on 8/9/25 regarding burn and pain, resident denied both. Identified resident had skin assessment completed on 8/10/25 by charge nurse and on call nurse practitioner notified. Treatment orders were received and implemented on 8/10/25. Nurses note entered on 8/10/25 by charge nurse of notification and orders received. The Electric urn used for self-service coffee was 676409 Page 5 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few disconnected on 8/10/25 by the Dietary Manager. The Dietary manger was reeducated by the Clinical Consultant on 8/10/25 on coffee service for residents including: temperature checks for hot beverages to include recording the start temperature and the serving temperature, between 155 degrees F and 175 degrees F on a temperature log. Coffee will be served into carafes from the commercial coffee maker in the kitchen and placed in the nourishment room for nursing staff to dispense as requested by residents.Kitchen staff were reeducated by the Dietary manger by 8/27/25 on coffee service for residents including: temperature checks for hot beverages to include recording the start temperature and the serving temperature, between 155 degrees F and 175 degrees F on a temperature log. Coffee will be served into carafes from the commercial coffee maker in the kitchen and placed in the nourishment room for nursing staff to dispense as requested by residents. An audit was completed by Nursing Leadership, Dietary Department and Administrator to identify residents in house who drink coffee. 20 were identified. Head to toe skin audits on the 20 identified residents were completed by the Licensed Nurses on 8/10/25 on paper and uploaded to the resident's medical record. No additional concerns were identified. An Evaluation will be completed on Residents who consume coffee to identify their ability to manage hot beverages independently by the Director of Nursing/Designee by 8/27/25. Those identified as needing assistance will have care plans updated by the Director of Nursing/Designee with needed safeguards individualized by resident needs to reduce the risk of burns from hot beverages. Clinical Consultant reeducated Administrator, Director of Nursing and Dietary Manager on appropriate notification and assessment if a coffee burn is identified on 8/10/25. Nursing staff and dietary staff were reeducated by the Director of Nursing/Designee on guidelines to reduce the risk of burns from hot beverages on 8/26/25 including: Pot or urns containing hot liquids will not be left unattended Facility staff will pour hot beverages Use of resident specific additional safeguards if indicated If a resident sustains an injury, an assessment from the licensed nurse will be completed immediately. Director of Nursing and physician will be notified for further direction This re-education will be completed by 8/26/25. Nursing staff or dietary staff not receiving this re-education by this date will receive prior to next scheduled shift. This will be provided for agency staff and new hire orientation through verbal education by the Director of Nursing/Designee. The Dietary Manager/Designee will assess newly admitted residents thorough the diet history observation in the electronic medical record Monday - Friday to identify those residents that request and/or consume coffee and communicate to the Director of Nursing/Designee to validate any needing assistance with hot beverages have care plans in place with needed safeguards. The Director of Nursing/Designee will review new admissions in clinical morning meeting Monday - Friday to validate residents identified as needing assistance with hot beverages have care plans updated with needed safeguards, recording on the clinical morning meeting form. The medical director was notified of the immediate jeopardy on 8/26/2025 by the administrator.An Ad Hoc Quality Assurance Performance Improvement meeting was held on 8/26/2025 regarding the contents of this plan. Monitoring on 08/27/2025 and 08/28/2025 included the following:Record review of Resident #4's care plan dated 07/16/25 reflected: Problem Start Date: 08/27/2025 Resident should have a lid on all hot liquids and should be sitting at a table while drinking or eating them. Goal Target Date: 12/27/2025 Resident will not get a burn Approach Start Date: 08/27/2025Resident to use cup with lid, temp will not exceed 175 degrees, resident should be sitting at table while eating or drinking hot fluids, staff to assist. 08/27/25 Regarding hot liquid safety, resident has some weakness in upper extremities and reduced movement in upper extremities, suggested interventions include that the resident will use a cup with a lid, hot liquids do not exceed 175 degrees, and that the resident should be drinking all hot fluids while sitting at a table while using a sippy cup and 676409 Page 6 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few has been seeing therapy. Record review of Resident #4's progress note dated 08/27/25 @ 10:00pm written by LVN S, regarding hot liquid safety, reflected resident has some weakness in upper extremities and reduced movement in upper extremities, suggested interventions include that the resident will use a cup with a lid, hot liquids do not exceed 175 degrees, and that the resident should be drinking all hot fluids while sitting at a table while using a sippy cup and has been seeing therapy. On 08/27/25 at 4:00 PM Observation of the dining room revealed the electric urn was removed. On 8/27/25 at 5:13 PM observation of the coffee urn in the locked nutrition room by the nurse's station revealed the item name, date, temperature reading, and employee initial. Dietary Staff R. On 8/27/25 at 5:15 PM Interview with the Dietary Manager who stated she worked at the facility for 10 months. She stated she was re-educated on abuse, neglect, rights, and coffee service for residents. She stated re-education on coffee services for residents included temperatures for hot beverages and had to be documented on a daily log. She stated the temperature had to be between 155 degrees- 175 degrees; not to exceed 175 degrees. She stated dietary staff use a stainless-steel thermometer. She stated the coffee urn is not to be left unattended. She stated facility staff would pour and serve hot beverages. She stated the facility ordered new coffee cups with lids. She stated they are using Styrofoam cups with tear back lids until the new cups arrive. She stated some of the residents use a specialized cup with lid. She stated coffee would be placed in the locked nutrition room for nursing staff to serve if residents request. She stated she was re-educated on reporting guidelines for hot beverage burns and proper procedure for handling and monitoring hot liquids. She stated she would report to the DON immediately. She stated she was re-educated on assessing newly admitted residents. She stated she would assess newly admitted residents the day after admission. She stated she goes over the resident's preferences and identifies residents that request coffee. She stated she documents in the resident profile under meal tracker, care plan, meal ticket and communicates with the DON alerting her of hot beverages the residents are getting and how often. She stated she would update preferences upon request by residents. She stated she re-educated all dietary staff on the hot beverage procedure, and daily coffee temperature log. She stated she put a sticker on the in-service sheet which showed the item, date, time, temperature, and staff initial. Coffee temperatures are checked before the urn is put on the food cart or brought to the nurse station which also include sticker. The urn for the dining room stays in the kitchen until nursing or CNA staff are in the dining room feeding and serving residents. Dietary staff are monitoring drinks during all meals in the dining room. She stated after meal services hot beverages will be put in the nutrition room for as needed services. On 08/27/25 at 5:45 PM Observed several staff in the dining room assisting residents with meal and drinks. Observed a Sign posted on the wall that said, Coffee available upon request located in the nutrition room between meals. Observed a coffee urn in the dining room on the counter which included a sticker with item, date, temperature reading 159 degrees, and staff initial. Observed staff pouring and serving coffee in a Styrofoam cup with lid and specialized cups to residents. On 08/27/25 at 5:56 PM Interview with Med Aide N who stated she had worked at the facility for 5 months. She stated she had been trained on abuse, neglect, rights, notification of resident change, and hot beverages. She stated staff are in-serviced every other week. She stated they went over the proper way of handling and serving the coffee. She stated coffee is served from an urn. She stated staff had to pour and serve all hot beverages. She stated staff serve coffee in Styrofoam cups with lids. She stated dietary staff check the temperature and put a sticker on the urn with the temperature before bringing it to the dining room. She stated the coffee cannot be brought out until the charge nurse is in the dining room. The coffee urn will never be left unattended.She stated if a resident asked for coffee, she would 676409 Page 7 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few tell the resident she would have to get with the charge nurse or offer a different type of beverage. She stated the temperatures should be around 155 degrees. She stated if a resident sustained an injury, she would immediately notify the nurse. On 08/27/25 at 6:10 PM Interview with CNA J. She stated she had worked at the facility 3 years. She stated she had been in-serviced on abuse, neglect, rights, notification of resident change and hot beverages. She stated staff are in-serviced every week. She stated staff had to pour and serve coffee for the residents. She stated coffee is served in styrofoam cup with a lid or specialized cup with lid. She stated the coffee is not to be left unattended, and when finished serving staff would take the coffee urn to the kitchen. She stated a coffee urn is kept locked in the nutrition room by the nurses' station. She stated the electric coffee urn was taken out of the dining room. She stated if a resident wanted coffee she would tell the resident to go to the dining room and she would bring coffee to them in a Styrofoam cup with a lid. She stated dietary staff check the coffee temperature and put a sticker on the coffee urn. She stated the coffee temperature ranges between 155degrees -175 degrees. She stated if a resident sustained an injury, she would immediately notify the nurse in charge. On 08/27/25 at 6:20 PM Interview with [NAME] F who stated she had worked at the facility for one year. She stated she had been in-serviced on abuse, neglect, rights, and checking the temperature for hot beverages and hot beverage policy. She stated staff are in-serviced monthly. She stated the big coffee pot had been taken out of the dining room. She stated nursing staff had to request coffee from the kitchen. She stated staff had to pour coffee for the residents and the coffee is now being served out of an insulated coffee pitcher. She stated temperatures are checked before coffee is brought to the dining room with a stainless-steel thermometer. She stated temperature checks for hot beverages include the start and serve temperatures. She stated temperatures should be between 155 degrees and 175 degrees and logged on a temperature log. She stated a label is put on the coffee pitcher which includes the item, date, time, temperature, and employee initial. She stated the coffee pitcher will not be left unattended. She stated coffee is kept locked in the nutrition room by the nurse station and staff had to serve the resident coffee. Record Review of in-service dated 08/10/25 reflected 3 administrative staff had been in-serviced on reporting guidelines for hot beverage burns and proper procedure for handling and monitoring hot liquids. Record Review of facility nutrition policies and procedures revision date 08/01/2020 reflected Precautions shall be implemented to limit the risk of burns from hot beverages (coffee, tea, etc.). 1. Hot beverages should be consumed at temperatures between 155 F and 175 F. Palatability is affected by temperature and varies from person to person, based on individual preference. 2. Commercial coffee brewing equipment is designed to heat water and hold coffee at desirable temperatures.A. Coffee should be brewed at temperatures between 195 F and 205 F to extract the full flavor. Storing coffee at temperatures between 175 F and 190 F will maintain the fresh brewed flavor for a limited period.B. Hot water dispensed from commercial coffee urns will be in the 185 F to 200 F range. 3. Pots or urns containing hot liquids should not be left unattended. 4. Facility staff should pour all hot beverages. 5. Locations where hot beverages may be prepared and/or re-heated such as employee break rooms or nourishment rooms should be safeguarded. 6. Patients or residents should not carry hot beverages without a lid while walking or moving in a wheelchair. 7. Beverages should not be re-heated by patients or residents or visitors. 8. The Facility may consider using china or ceramic cups, in lieu of plastic mugs, or foam cups, which do not provide for rapid cooling. 9. When serving hot beverages to patients or residents:A. Transfer the beverage from its brewing urn to a serving container. Beverages served directly from the brewing urn will be hotter.B. Do not overfill cups.C. Explain to patient/resident that a hot beverage is being served.D. Place cup away from the edge of the table and 676409 Page 8 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few within patient's/resident's field of vision and reach of dominant hand.E. Remove lids to allow beverage to cool faster.10. When hot beverages are available for self-service: (e.g. dining room, lobby, beverage cart on unit)A. Coordinate beverage set-up in supervised areas only.B. Transfer the beverage from its brewing urn to a serving container.C. Do not overfill serving containers.D. Use only containers with safety or screw top lids rather than loose lids.E. Pre-pour beverages whenever possible into cups with lids. Record Review of in-service dated 08/10/2025 reflected that 5 staff had been in-serviced on hot beverage procedures regarding start and serving temperature and check of the beverage until it has reached a temperature range of 155 degrees-175 degrees per company policy. Once the proper temperature is reached staff will write out a ticket of type of beverage, date, time, and temperature. No hot beverage will be put out for serving until nursing staff is there to start. After all meal services hot beverages will be put in the nutrition room for as needed service. Record Review of skin monitoring: comprehensive CNA shower review dated 08/11/2025 reflected head to toe audits for 19 residents who drink coffee. No concerns were noted. Record Review of hot beverage temperature log sheet for August 2025 reflected start and serve temperatures. No concerns were noted. On 08/28/25 at 12:42 PM Interview with LVN E who stated she had worked at the facility for 2 years.She stated she had been in-serviced on abuse, neglect, rights, notification of resident change, and hot beverages and hot cereal. She stated staff are in-serviced every two weeks. She stated the coffee is served in an urn with a handle. She stated they went over serving temperature which is 155 degrees. She stated dietary staff check coffee temperature in the kitchen and put a label on the urn which includes the item, date, temperature, and staff initial. She stated the coffee is brought to the dining room when nursing staff is in the dining room and urns containing hot liquids will not be left unattended.She stated staff had to pour and serve hot beverages to the residents. She stated staff use Styrofoam cups with lids. She stated some of the residents have a specialized cup with lid. She stated the Administrator had ordered new cups with lids; they are using Styrofoam cups with lids until the new cups arrive. She stated coffee is kept in the nutrition room for nursing staff to dispense if residents request. She stated most of the residents that drink coffee are independent.She stated if a resident sustained an injury she would immediately assess the resident, notify the family, DON, and PCP. On 08/28/25 at 12:57 PM Interview with [NAME] O who stated she had worked at the facility for 1 year. She stated she had been in-serviced on abuse, neglect, rights, and hot beverages and cereal. She stated staff are in-serviced once a month. She stated dietary aides are supposed to check the temperature when coffee is freshly brewed and served. She stated the serving temperature should be between 155 degrees -175 degrees. She stated dietary staff had to wait until nursing staff asked for the coffee to be brought to dining room. She stated the coffee is served in an urn with a label which included item, temperature, date and staff initials. She stated the nursing staff had to pour the coffee and serve to residents. She stated coffee is poured in Styrofoam cups with a lid until the new cups and lids arrive. She stated coffee will not be left unattended. She stated a coffee urn is placed in the nutrition room for staff to dispense if residents request. She stated dietary staff also have to check the temperature and label the hot cereal. She stated a temperature log is kept daily for hot beverages. Temperatures are checked with a stainless-steel thermometer. She stated if a resident asked for coffee she would tell the resident to go ask the nurse. She stated if a resident sustained an injury, she would immediately notify nursing staff. On 08/28/25 at 1:15 PM conducted Interview with CNA P who stated he had worked at the facility for about 4 months. He stated he had been in-serviced on abuse, neglect, rights, hot beverages, and notification of resident change. He stated staff are in-serviced monthly. He stated coffee is served from an urn and only when nursing staff is 676409 Page 9 of 10 676409 08/28/2025 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in the dining room. He stated coffee is not to be left unattended in the dining room. He stated after meals the coffee is brought to the nutrition room which is kept locked. He stated the temperature should be between 155 degrees -175 degrees. He stated the coffee is served in an urn which had a sticker that shows the item, temperature, and staff initial. He stated staff pour and served the coffee for residents. He stated if a resident asked for coffee, he would go get the coffee and bring it to the resident. He stated most of the coffee drinkers are independent. He stated coffee is served in a Styrofoam cup with lid. He stated some of the residents had a specialized cup with lid. He stated if a resident sustained an injury he would immediately report to the nurse in charge. Record Review of in-service dated 08/10/2025 reflected 13 staff from different shifts had been in-serviced on abuse, neglect, and resident rights. Record Review of in-service dated 08/10/2025 reflected 18 staff had been in-serviced on the hot beverage policy. Record Review of evaluations completed for all residents. Their criteria were all the same for the evaluations. Residents were screened for cognition, mobility, dexterity, and behaviors to see if they were safe with hot beverages. Record Review of facility daily monitor log for appropriate hot beverage cup/lids reflected 08/11/25 through 08/15/25 no concerns. On 08/28/25 at 3:00 PM conducted Interview the DON stated she had worked at the facility for four months.She stated she had been trained on abuse, neglect, resident rights, and hot beverages. She stated the electric urn was discontinued immediately. She stated coffee is being served from an urn. She stated the dietary manager, DON, and Administrator were reeducated on coffee service for the r[TRUNCATED] 676409 Page 10 of 10