Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #44)
reviewed for medication administration were free of significant medication errors.
Residents Affected - Few
MA L administered Doxazosin Tablet 4mg and Amiodarone HCl Tablet 200mg (medications used to treat
high blood pressure), while Resident #44 was assessed with blood pressure lower than the physician
recommended parameters for administering the medications.
This failure could place residents at risk for not receiving therapeutic effects of their medications and
possible adverse reactions.
Findings included:
Review of Resident #44's face sheet, dated 05/02/2024, revealed that the resident was a [AGE] year-old
male who was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart
failure (condition that occurs when high blood pressure damages the heart and reduces its ability to pump
blood effectively).
Review of Resident #44's quarterly MDS assessment, dated 03/25/24, revealed a BIMS score of 15 (an
intact cognitive response.
Review of Resident #44's May/2024 active Physician Order Summary revealed the following orders:
Amiodarone HCl Tablet 200 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY)
HYPERTENSION (I10) Hold For SBP<110 DBP<60
Doxazosin Mesylate Tablet 4 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY)
HYPERTENSION (I10) Hold for SBP<110 DBP<60
Observation on 05/02/2024 at 8:15am revealed MA L was observed obtaining Resident #44's blood
pressure with a blood pressure reading of 100/65. MA L proceed by administering the medications and
verbalizing to Resident #44 that he was receiving all morning medications including blood pressure
medications.
Review of Resident #44's May/2024 Medication Administration Record (MAR) revealed that MA L
administered Doxazosin Tablet 4mg and Amiodarone HCI Tablet 200mg. Each of the medications were
administered outside of the physician indicated parameters on 05/02/2024. Resident #44's systolic blood
pressure was documented by MA L with a systolic blood pressure of 100 and a diastolic blood pressure of
a
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
675233
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
675233
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Care at Golfcrest
6150 S Loop East
Houston, TX 77087
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 0760
65.
Level of Harm - Minimal harm
or potential for actual harm
Interview with MA L on 05/02/2024 at 8:20am, MA L denied administering Resident #44's blood pressure
medication, stated that she had discarded the medication in Resident #44's designated trash bin in his
room. There was no observation of the referenced discard of the medications.
Residents Affected - Few
Interview and observation with ADON on 05/02/2024 at 8:30am, ADON was notified of the surveyor's
observation of MA L administering blood pressure medication outside of the indicated parameters; and MA
L denial of administering the medications. ADON proceeded to assess Resident #44 for adverse side
effects. The ADON stated that MA L was not able to produce the pills and that the medication was not in the
trash bin as alleged by MA L. The ADON stated that MA L later disclosed that she had administered the
medications. The ADON stated that the physician was notified. MA L was removed from the floor and
provided in-service and educated on medication administration.
Interview on 05/02/2024 at 9:30AM with MA L, MA L stated that if blood pressure medication is
administered outside of the recommended parameters, the resident's blood pressure could drop too low
causing the resident to have severe complications. MA L stated that staff administering the medications
was responsible for ensuring that a medication was given within recommended parameters. MA L stated if
blood pressure medication was given out of recommended parameters the medication could cause the
blood pressure to become too elevated or too low.
Observation on 05/02/2024 at 9:33 AM revealed Resident #44 was observed sitting in bed watching
television. Resident reported that he was feeling well.
Interview on 05/02/2024 at 1:22 PM with the DON, stated that MA L later disclosed that she had
administered the medications. The DON stated that the physician was notified. MA L was removed from the
floor and provided in-service and educated on medication administration. The DON stated medication
should be held if the vitals were out of parameters. The DON stated the medication aide should have
notified the nurse and the nurse would have notified the doctor that the medication was not administered
because the resident's vitals were out of parameters. The DON stated that the purpose of the
recommended parameters for the medication is to ensure that the resident remains in a safe blood
pressure range identified for the resident.
Review of the facility's Medication Administration policy, not dated, reflected: .Medications must be
administered in accordance with the written orders of the physician's order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675233
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
675233
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Care at Golfcrest
6150 S Loop East
Houston, TX 77087
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve
food in accordance with professional standards for food service safety for 1 of 1 kitchen in that:
Residents Affected - Some
1.
Food items were not sealed and/or not dated in the facility pantry .
2.
One can of canned food was dented and stored with the non-dented food cans .
These deficient practices could place 89 residents who received meals from the main kitchen at risk for
food borne illness.
Findings included:
1. Observation in the pantry of the food items on 04/30/24 at 08:32 am revealed one 16 oz bag of tortilla
chips was opened, not sealed, not dated.
Observation in the pantry of the food items on 04/30/24 at 08:33 am revealed one 80 oz bag of instant
oatmeal was dated, not sealed.
Interview with the Dietary Manager on 4/30/24 at 2:08 pm she said the food items that were not sealed
should have either been destroyed or their entire contents should have been used because of the small
amount of food that was in the bags. She said all kitchen staff were responsible for checking if food is
sealed and dated in the pantry. She said she would go behind kitchen staff and double check food items in
the pantry. She said the risk to the resident would be food poisoning.
Interview with the Dietary Aide on 4/30/24 at 2:14 pm, she said she has worked at the facility for 8 months.
She said kitchen staff were supposed to store leftover food in Ziploc bags and date. She said everyone in
the kitchen was responsible for labeling and dating opened food items. She said the risk to the resident
could make them sick.
Interview with the Dietary [NAME] on 4/30/24 at 2:22 pm she said she has worked at the facility for 1 year
and 5 months. She said the food items in the pantry were supposed to be stored in a Ziploc bag and dated.
She said everyone in the kitchen was responsible for labeling and dating food items and the next shift
would check for food items in case any were missed by the previous shift. She said the risk to the resident if
food items were not sealed or dated would cause the resident to get sick.
2. Observation in the pantry of the non-dented cans on 04/30/24 at 08:35 AM revealed one 104 oz can of
apples in water had a small dent on the bottom of the seam.
Interview with the Dietary Manager on 4/30/24 at 8:36 am confirmed the dented can of apples should have
been stored with the dented cans.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675233
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
675233
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Care at Golfcrest
6150 S Loop East
Houston, TX 77087
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview with the Dietary Manager on 4/30/24 at 2:09 pm, she said the dented cans should be stored on a
separate shelf away from the non-dented cans. She said everyone in the kitchen was responsible for
checking dented cans and she would go behind to double check. She said the risk to the resident would be
exposure to botulism.
Interview with the Dietary Aide on 4/30/24 at 2:15 pm, she said dented cans should be stored away from
regular cans in their own designated area. She said kitchen staff go behind each other to double check for
dented cans. She said the risk to the resident would cause them to get sick.
Interview with the Dietary [NAME] on 4/30/24 at 2:23 pm, she said the dented cans should be stored on a
separate shelf. She said everyone in the kitchen should check for dented cans. She said each shift goes
behind the previous shift and checked for dented cans. She said the risk to the resident would cause them
to get sick.
Record review of the facility's Food Receiving and Storage undated policy under section 13e read in part .
opened containers must be dated with use by date and sealed or covered during storage .
Record review of the U.S. Food and Drug Administration dated 1/18/23 under Chapter 3 read in part . FDA
considers food in hermetically sealed containers that are swelled or leaking to be adulterated and
actionable under the Federal Food, Drug, and Cosmetic Act .rusted and dented cans may also present a
serious potential hazard .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675233
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
675233
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Care at Golfcrest
6150 S Loop East
Houston, TX 77087
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 0851
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and
other verifiable and auditable data.
Based on interview and record review, the facility failed to electronically submit to CMS complete and
accurate direct care staffing information, including information for agency and contract staff, based on
payroll and other verifiable and auditable data in a uniform format according to specifications established by
CMS for 1 of 4 quarters (1st quarter October 1, 2023-December 31, 2023) reviewed for fiscal year quarter
one of 2024.
The facility failed to submit staffing information to CMS for the 1st quarter of the fiscal year 2024.
The facility's failure could place residents at risk for personal needs not being identified and met, decreased
quality of care, and a decline in health status.
The findings included:
Review of the facility's staff roster indicated the following:
1 Administrator
7 Administrative Staff
6 Nursing Administration (Includes 1 DON)
86 Nursing Staff (includes 2 ADON)
28 Therapist (Includes Respiratory Therapy and Rehabilitation Services)
11 Dietary Staff
10 Housekeeping/Laundry Staff
2 Activities Staff
1 Social Service Staff
2 Maintenance Staff
Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 1 2024 (October
1 - December 31, 2023), dated 04/25/2024, revealed the following entry: Failed to Submit Data for the
Quarter .Triggered=No data submitted for quarter.
Interview on 05/02/24 at 11:02 a.m. with the Regional Director of Clinical Operations. She said an outside
3rd party HR company was responsible for submitting payroll and the PBJ for the facility. Due to the lapse in
submitting the PBJ by the deadline, the contract with the HR 3rd party company was terminated in
February 2024. The risk of not submitting the PBJ per guidelines was that the facility was not reporting
staffing accurately and not getting credit for being adequately staffed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675233
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
675233
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harmony Care at Golfcrest
6150 S Loop East
Houston, TX 77087
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 0851
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 05/03/24 at 10:52 a.m. with the Administrator, who said he started working at the facility on
March 14, 2024. He said he was unaware that the PBJ had not been submitted for the 1st quarter of 2024
until the survey team arrived, and it was being discussed with the Clinical Operation Director on 5/2/24. He
said the Clinical Operations Director will be responsible for submitting the PBJ for the next quarter. The
Administrator said late or omitted PBJ submissions was a deficient practice because the report did not
accurately capture the staffing component at the facility to meet the needs of the residents.
Record review of facility provided policy and procedure entitled Reporting Direct-Care Staffing Information
(Payroll-Based Journal), revealed in part: 9. Staffing information will be collected daily and reported for each
fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Fiscal
Quarter 1 .Date Range .October 1-December 31 .Submission Deadline .February 14 .Fiscal Quarter 2
.Date Range .January 1-March 31 .Submission Deadline .May 15 .Fiscal Quarter .3 .Date Range .April 1June 30 .Submission Deadline .August 14 .Fiscal Quarter 4 .Date Range .July 1- September 30
.Submission Deadline .November 14.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675233
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F851 - Mandatory submission of staffing information based on payroll data in a
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
FAQ · About this visit
Common questions about this visit
What happened during the May 3, 2024 survey of Harmony Care at Golfcrest?
This was a inspection survey of Harmony Care at Golfcrest on May 3, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Harmony Care at Golfcrest on May 3, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.