Health inspection·December 10, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some white bedsheet. Both items appeared to be wet and saturated with liquid. CNA A repeated that the items did not belong in the rubbish bin and that she did not know how the items got inside the trash bin. CNA A tried to bring a linen barrel to Resident #3's bedroom door to remove the linens but the Administrator and DON arrived at the resident's room prior to the removal of the items. The DON removed the bundled items with her gloved hands, that CNA A had placed back into the bedside trash bin and said it was a soiled Hoyer sling used for resident transfers and a soiled bedsheet. The DON said they did not belong inside a resident's bedside trash bin because it could spread infection if not handled and disposed of properly. The DON said the IP would do an immediate reeducation with assigned staff member CNA A. The Administrator asked what the items were and when shown the soiled linens, by the DON said they did not belong inside the trash bin and he and the DON would speak with the staff member involved and retrain them because staff had been trained on how to handle and dispose of linens properly as part of infection control training. The Administrator said leaving soiled linens in a trash bin in any resident room could spread infection. CNA A was observed speaking with the DON, LVN A and the Administrator while she began removing the soiled linens out of the trash bin and placing them in the required linen receptacle. Resident #4 Record review of Resident #4's admission Record revealed he was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility 9/17/25 with a diagnosis of acute and chronic respiratory failure ( a condition where a person with an underlying chronic respiratory disease experiences a sudden and severe worsening of their breathing), colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall which allows stool and gas to pass directly into a collection bag worn on the outside of the body), tracheostomy status (a surgical procedure that creates an opening in the front of the neck into the windpipe for breathing), gastrostomy (a surgical procedure that creates an opening in the abdominal wall directly into the stomach that allows a tube to be inserted into the stomach for feeding), and peripheral vascular disease ( a condition where the blood vessels outside the heart and brain become narrowed or blocked, reducing blood flow to the limbs). Record review of Resident #4's Admission, 5-day MDS dated [DATE] revealed he had a Staff Assessment for Mental Status (SAMS) and was coded as severely impaired in cognitive skills for daily decision making and he was dependent on staff for assistance with all ADLs. Record review of Resident #4's physician order summary dated active orders as of 10/08/2025 revealed the following order: enhanced barrier precautions AEB colostomy and had a start date of 6/13/2025 with no stop date. Observation on 10/7/2025 of Resident #4 at 12:22 p.m., who was located in the room across the hallway from Resident #3 and had an EBP sign posted on the door and an adequate supply of PPE outside the bedroom door. Resident #4 had a navy-blue blanket lying on the floor in a bundle on the floor at the foot of his bed. Resident #4 was appropriately dressed and groomed and was lying on an air mattress in a clean facility gown with a clean white sheet at the end of the bed. His gastrostomy tube was connected to his enteral feeding (a method of providing nutrition directly into the stomach through a tube), that was infusing via a bedside pump as per MD orders. His tracheostomy and collar were in place and secured with his oxygen infusing via bedside concentrator per MD orders. In an interview and observation on 10/7/25 at 12:24 p.m., CNA A entered Resident #4's room and picked up the navy-blue banket off of the floor and began to shake it out in an attempt to line up the corners and edges of the blanket to fold it. CNA A said that Resident #4 did not like to keep the sheets and blankets on and would kick them off sometimes when he did not want them. CNA A began to place the navy-blue blanket across the lower legs and feet of Resident #4 before the surveyor stopped her. When asked why she would put the blanket from the floor back on the resident's bed and not in the dirty linen barrel, she replied, I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 2 of 5 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 12/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete guess I can. CNA A walked out of Resident #4's room rapidly before the surveyor could ask another question and was not seen at the facility for the remainder of the investigation. Interview with the IP on 10/8/25 at 9:20 a.m., who said they completed a 1:1 in-service training with CNA A on 10/7/25 and that CNA A had also been trained on infection control and proper linen handling prior to the incident with Resident #3 and Resident #4 on 10/7/25. The IP said both Resident #3 and Resident #4 were on EBP and could get infections, worsen any existing infections or illnesses if their linens were not handled properly. The IP said both Resident #3 and Resident #4 had tracheostomy and gastrostomy tubes and that was the reason for their EBP status. Record review of training in infection control that included proper handling of linens that CNA A signed on 10/7/25 and 8/12/25. Record review of facility policy and procedure titled Enhanced Barrier Precautions dated 2021 revealed in part: Enhanced Barrier Precaution's (EBP's) are utilized to reduce the transmission of multi drug resistant organisms (MDRO's) to residents.5. EBP's are indicated (when contact precautions do otherwise not apply) for residents with wounds and or indwelling medical devices. Record review of facility policy and procedure titled Standard Precautions dated 2021 revealed in part: a. linen soiled with blood, body fluids, secretions, excretions, are handled and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and avoids transfer of microorganisms to the other residents and environments. Event ID: Facility ID: 675233 If continuation sheet Page 3 of 5 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 12/10/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside.Based on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 out of 10 (Resident #2) of the residents reviewed for call-lights. The facility failed to ensure Resident #2 had a functioning call light, the call light was empty inside the device, presenting only the white outer coating. This failure could lead to residents not being able to request and receive prompt medical care and result in injury and harm.Findings included:Record review of Resident #2's face sheet, dated, reflected an [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted [DATE] with a diagnosis of (a systemic infection with life threatening organ dysfunction), quadriplegia (a medical condition characterized by the partial or complete loss of movement and sensation in all four limbs), cerebral edema (a condition where excessive fluid accumulates in the brain tissue, causing it to swell), methicillin-resistant staphylococcus aureus (a strain of bacteria that is resistant to the antibiotic methicillin and other similar antibiotics), tracheostomy status (a surgical procedure that creates an opening in the front of the neck into the windpipe for breathing), pressure ulcer of sacral region, stage 4 (a severe wound that involves full-thickness skin and tissue loss with exposed underlying structures like muscle, tendon, ligament, cartilage or bone), and gastrostomy (a surgical procedure that creates an opening in the abdominal wall directly into the stomach that allows a tube to be inserted into the stomach for feeding).Record review of Resident 's Modified admission MDS dated [DATE] revealed she had a Staff Assessment for Mental Status (SAMS) and was coded as being severely impaired in cognitive skills for daily decision making. She was dependent on staff for assistance with all ADLs.Record review of Resident #2's physician order summary dated active orders as of 10/08/2025 revealed the following order: enhanced barrier precautions for wounds, and had a start date of 9/13/2025, with no stop date. Record review of Resident #2's care plan reflected she was at risk for falls, aspiration related to feeding tube in place, respiratory distress, impaired communication, self-isolation, shortness of breath, chest pain, elevated blood pressure. --Receiving (In-house dialysis) She was also care-planned for self-care deficits related to ADLs and requires total assistance for bathing, dressing, eating, mobility, and risk further decline due to trach placement and cognition.Observation and attempted interview on 10/07/2025 at 11:25 a.m., Resident #2 was in bed with contracted hand near call light exposing an empty hold where the push device would be located inside the outer white casing. The resident was not able to be interviewed and did not respond to questions. Interview and observation on 10/07/25 at 12:08 p.m., the Administrator and DON, employed at the facility since January 2025, he said maintenance and the nursing staff should check to make sure the call lights were in good condition before they were placed within reach for the resident for them to use. The Administrator said if the call button being functioning the residents would not be able to alert staff for assistance or harm. The Administrator said that residents might need medication, and if they did not have their call light within reach there could be a multitude of things that could go wrong. The Administrator said the call light in Resident #2's room will be changed and staff provided in services. He picked up the call light to observe the push button portion of the call button missing. The DON, she said all residents should always have Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 4 of 5 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 12/10/2025 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete call light with reach. The DON observed the call light laying on the resident's bed. The DON said it is a safety issue in case the resident needed to request care. The DON said immediate reeducation with staff and maintenance would occur. Interview on 10/08/25 at 12:25 p.m., CNA A employed at the facility for seven months, she said the expectation is to check residents every two hours or as needed. She stated she did not know Resident #2's call light was not functioning. She stated she is aware Resident #2 was a nonverbal resident, and she is only mobile with assistance. She stated she was made aware the call light was not working on 10/07/2025. She stated she knows she was supposed to check the call lights. She said that it was on staff for not checking her call light to know it was broken. She said she had been working with Resident #2 for a month and a half. Interview on 10/07/25 at 12:34 p.m., CNA B, employed at the facility for two years, stated she was not aware of Resident #2 call light being broken. She said that Resident #2 was not a resident room that she works with often. She said all its staff can check for call button function. She said very serious outcomes can occur when a call light is not operating such as falls, aspiration, or death. Interview on 10/07/25 at 12:45 p.m., LVN A, employed at the facility for one week, she stated she was not aware of Resident #2 call light being broken. She said she worked at the opposite end of the hallway and is not familiar with Resident #2. She said very serious outcomes can occur when a call light is not operating such as falls, chocking, or death. Interview on 05/22/25 at 1:33 p.m., the HR/Payroll Director, employed at the facility for many years, said she said she confirms the rooms are ready to move and checks call lights for proper functioning and operating daily. She said the CNAs check resident's morning, lunch, and she stated anyone can answer call lights at the community. She said the expectation is to check residents every two hours or as needed. She said she was not aware of Resident #2's call light being broken. She said she is aware the call light has been changed and replaced with a more accessible call light and in-service has been provided.Interview on 05/22/25 at 1:40 p.m., the Maintenance Director, who has been employed at the facility since 2001, said he confirms all call lights are functioning properly and operating. He stated that anyone can answer call lights at the community. He said call lights are his main priority at the community. He said he checks call lights weekly. He said companies do not make call lights like they used to; they break easier than they used to. He said he always keeps 10 extra buttons just in case they are needed. He said last Friday he checked all the call buttons in the building and Resident #2 light was not broken. He said he does not recall a resident being in that room. He said if a call light is pulled out it will sound off continuously until it is replaced with another button. He said sometimes the CNAs may switch broken buttons out themselves and not report it to maintenance, that's what could have happened. He said he really does not know how he could have missed a broken button because he conducted a thorough audit of call lights last Friday.Record review of the maintenance binder did not reflect any broken call light reports related to Resident #2. Record review of the facility's call lights policy last revised 09/2022 read in part, The Facility will provide each resident with a means to call staff directly for assistance from his or her bed for from toileting/ bathing facilities and from the floor. The call system communication may be audible or visual, wired or wireless. The resident calls system remains functional at all times, if audible communication is used the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights must remain functional. If the resident has a disability that prevents him or her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan. The resident call system is routinely maintained and tested by the maintenance department. Event ID: Facility ID: 675233 If continuation sheet Page 5 of 5