Health inspection·January 18, 2023

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to ensure good retention of training 2. Record review of Resident #87's face sheet, dated 01/17/2023, revealed an admission date of 11/15/2022, and a readmission date of 12/06/2022, with diagnoses which included: Gastrostomy status (opening into the stomach from the abdomen made surgically for the introduction of food), Type 2 diabetes mellitus(high level of sugar in the blood), Dementia (progressive impairments in memory, thinking, and behavior), Parkinson's(long-term degenerative disorder of the central nervous system), Colostomy status(opening in the large intestine), Hypertension(high blood pressure) Record review of Resident #87's 5 days MDS, dated [DATE], revealed the resident had a BIMS score of 3 indicating severe cognitive impairment. Resident #87 required extensive assistance to total care, had an indwelling catheter and a colostomy. Observation on 01/17/23 at 01:50 p.m. revealed during colostomy care the privacy curtain at the end of Resident #87's bed was left completely open by LVN D. Anybody opening the bedroom door would have had a full view of the resident. During an interview with LVN D on 01/17/2023 at 2:05 p.m., LVN D verbally confirmed the privacy curtain was not closed while she provided care for Resident #87 but it should have been to provide privacy and ensure dignity. During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #87's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and they are doing return demonstration to insure good retention of training 3. Record review of Resident #92's face sheet, dated 01/17/2023, revealed an admission date of 08/23/2022, with diagnoses which included: Epileptic syndrome (seizure), Asthma (Chronic disease of the respiratory system), Down syndrome (A genetic disorder associated with physical growth delays, characteristic facial features and mild to moderate developmental and intellectual disability), Hyperlipidemia (Too much fat in the blood) Record review of Resident #92's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #92 required extensive assistance, was occasionally incontinent of bladder and frequently incontinent of bowel. Observation on 01/17/23 at 10:15 a.m. revealed during incontinent care the privacy curtain was too short to completely surround Resident #92's bed. The resident's roommate was in her bed and Resident #92's genitals were exposed during care. During an interview with CNA F and CNA G on 01/17/2023 at 10:25 a.m., the CNAs verbally confirmed the privacy curtain was not completely closed while they provided care for Resident #92 but it should have been to provide privacy and ensure dignity. They confirmed the curtain was too short to completely close around the bed. During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed privacy must be provided during nursing care and Resident #92's privacy curtains should have been closed completely. She confirmed the staff received training about Residents' rights and residents' privacy and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 2 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0583 they are doing return demonstration to insure good retention of training Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Residents Rights, undated, revealed, When providing resident care, always provide privacy [ .] pulling a curtain around the bed, pulling the drapes to windows, closing the door and draping the resident's body appropriately. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 3 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to accurately reflect the resident's status for 2 (#27 and #90) of 8 residents reviewed for assessments in that: Residents Affected - Few 1 Resident #27 was on continuous oxygen therapy and it was not reflected in her MDS assessment during the 7 day lookback. 2. Resident #90 had a LCS diet ordered and it was not reflected that she was on a therapeutic diet during the 7 day lookback. This deficient practice could affect residents who receive assessments and could result in improper care. The findings were: 1. Review of Resident #27's electronic face sheet dated 01/15/2023 revealed she was admitted to the facility on [DATE] with diagnoses of heart failure (a progressive heart disease that affects the pumping action of the heart muscles), myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries), chronic obstructive pulmonary disease, (COPD) (persistent respiratory symptoms like progressive breathlessness and cough) atrial fibrillation (abnormal heart rhythm) and cardiac pacemaker (surgical insertion of a small device under the collarbone to control the electrical events of the heart). Review of Resident #27's Annual MDS assessment with an ARD of 12/17/2022 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. Resident #27 was not coded to be on oxygen therapy. Review of Resident #27's comprehensive care plan with a revision date of 09/12/2022 revealed under Focus .has oxygen therapy r/t COPD .Interventions .Oxygen settings: The resident has O2 at 2L continuously. Review of Resident #27's Active Orders As Of: 01/16/2023 revealed Continuous O2 at 2L per n/c to maintain O2 sat >92% .with a start date of 09/29/2022. Review of Resident #27's vital signs record for the dates of 12/10/2022 to 12/17/2022 revealed she had oxygen saturations taken at least two times a day with oxygen on via nasal cannula. Review of Resident #27's MAR dated 12/01/2022 to 12/31/2022 reveaeled nurses initialed off that she had continuous O2 at 2L per n/c every day. Observation on 01/15/2023 at 10:56 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/NC. Observation on 01/16/2023 at 09:55 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/NC. Interview on 01/15/2023 at 11:00 a.m. with Resident #27, she stated she was on oxygen continuously (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 4 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0641 since she was admitted to the facility. She stated she did not adjust the oxygen, only the nurses did that. Level of Harm - Minimal harm or potential for actual harm Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator B revealed that the Annual MDS assessment with an ARD of 12/17/2022 for Resident #27 was inaccurate and should have had the oxygen coded. She stated I'm not sure what happened, I missed that one completely. Residents Affected - Few 2. Review of Resident #90's electronic face sheet dated 04/19/2022 revealed she was admitted to the facility with diagnoses of diabetes mellitus (condition that results from insufficient production of insulin, causing high blood sugar), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and anemia (deficiency of healthy red blood cells, causing fatigue and weakness). Review of Resident #90's Quarterly MDS assessment with an ARD of 11/04/2022 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #90 was on a mechanically altered diet but was not coded for a therapeutic diet. Review of Resident #90's comprehensive care plan with a revision date of 05/09/2022 revealed Focus .has the potential for a nutritional problem r/t protein calorie malnutrition .diet: FMP, pureed diet with nectar thin liquids. Review of Resident #90's Active Orders As Of: 01/16/2023 revealed Diet: FMP, Pureed, Nectar Consistency, LCS. active as of 04/30/2022. Observation on 01/16/2023 at 12:00 p.m. of Resident #90 revealed she was in the dining room and was assisted with eating, her meal ticket read, FMP, Pureed, Nectar Consistency, LCS diet. Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator A revealed that the Quarterly MDS assessment with an ARD of 11/04/2022 for Resident #90 was not accurate, and stated the therapeutic diet, should have been coded since Resident #90 has an LCS diet ordered. MDS Coordinator A further revealed the FSS would have entered the diet information however did confirm the MDS coordinators are responsible for ensuring the assessments for accuracy at each review. Review of the facility policy and procedure titled Resident Assessment Instrument Process (undated) revealed The MDS Coordinator and Nursing Staff are key members of the interdisciplinary team in this facility. One of the functions in the RAI/MDS process is to gather data in order to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 revealed The RAI process has multiple regulatory requirements .(1) the assessment accurately reflects the resident's status .an accurate assessment requires collecting information from multiple sources. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 5 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan for 3 (#28, #37 and #90) of 16 residents reviewed for comprehensive care plans in that: 1. The facility failed to update Resident #28's comprehensive person-centered care plan to reflect the change to an NPO diet with enteral feedings (deliver nourishment through a tube directly into the gastrointestinal tract). 2. The facility failed to update Resident #37's comprehensive person-centered care plan to reflect the change to a fortified meal plan diet with pureed texture. 3. The facility failed to update Resident #90's comprehensive person-centered care plan to reflect she was ordered a LCS diet. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care. The findings were: 1. Record review of Resident #28's face sheet dated 01/17/2023 revealed an initial admission date of 09/01/2015 with a recent admission of 08/02/2022 and diagnoses which included: benign neoplasm (noncancerous abnormal growth of tissue) of cerebral meninges (protective tissue surrounding the brain), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dysphasia (impairment of the ability to communicate). Record review of Resident #28's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated moderate cognitive impairment. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #28 was on a feeding tube while a resident of the facility but was not coded for a mechanically altered diet. Record review of Resident #28's Care Plan, undated, revealed a focus, [Resident] has a nutritional problem r/t protein calorie malnutrition, neurological issues, history of leukemia and other comorbidities (two or more diseases or medical conditions at the same time). Diet: FMP Regular diet with supplements and thin liquids. Revision 03/12/2022. Further review revealed another focus, The resident requires tube feeding r/t Dysphagia. Revision 10/03/2022. Focus area revealed from revision on 04/13/2021, [Resident] has a potential nutritional problem r/t eating disorder .current diet: FMP Regular diet with thin liquids. Enriched cereal topping at breakfast, yogurt daily, no gravy, add ice cream for lunch and dinner. An intervention for the focus was: Provide, serve Mech (mechanical) soft diet. Revision on 10/18/2022. Record review of Resident #28's electronic clinical record, Order Summary Report with Active Orders as of 01/18/2023, revealed a dietary order, dated 08/02/2022, NPO diet Dysphagia texture. Further review revealed an enteral feed order, dated 01/03/2023, Enteral Feed Order three times a day for meal replacements Osmolite (high-protein tube-feeding formula) 1.5 Bolus (a discrete amount within a specific time) 8 fl oz 3 times daily for meal substitutions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 6 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #28's electronic clinical record progress notes revealed a Speech therapy note, dated 11/07/2022, Patient discharged from ST services. It is recommended patient remain NPO at this time. Patient given trial of puree with outward s/s of aspiration noted during intake with strategies in place. 2. Record review of Resident #37's face sheet dated 01/18/2023 revealed an admission date of 02/15/2021 and diagnoses which included: dementia (inability to remember, think or make decisions), anemia (lower-than-normal amount of healthy red blood cells), protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and dysphagia (difficulty swallowing). Record review of Resident #37's Quarterly MDS, dated [DATE], revealed Resident #37 was not a candidate for a BIMS which indicated severe cognitive impairment. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #37 was on a mechanically altered diet while a resident of the facility. Record review of Resident #37's Care Plan, undated, revealed a focus, [Resident] has the potential nutritional problem r/t protein calorie malnutrition, having severe dementia, short attention span, ADL care refusal at times and other comorbidities. Diet: FMP Mechanical Soft diet with thin liquids. Date Initiated: 03/02/2022. Revision on: 03/02/2022 Record review of Resident #37's electronic clinical record, Order Summary Report with Active Orders as of 01/18/2023, revealed a dietary order, dated 10/28/2022, Fortified Meal Plan diet Pureed texture, Regular/Thin consistency, ALLERGY IODINE NO SEAFOOD: ice cream w/lunch and dinner. double super cereal with breakfast. Further review revealed a supplement order, dated 11/10/2022, Health Shake three times a day for Supplement. In an interview with MDS Coordinator B on 01/18/2023 at 11:48 a.m., MDS Coordinator B confirmed the care plan had not been revised to reflect Resident #28's and Resident #37's diets. MDS Coordinator B stated the previous diets should have come off (care plan), it clearly was an oversight. When asked about potential harm of not updating a care plan, MDS Coordinator B stated that if a staff member used the care plan to follow what diet the resident should be receiving, the staff could provide an unsafe meal to their resident. 3. Review of Resident #90's electronic face sheet dated 04/19/2022 revealed she was admitted to the facility with diagnoses of diabetes mellitus (condition that results from insufficient production of insulin, causing high blood sugar), dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and anemia (deficiency of healthy red blood cells, causing fatigue and weakness). Review of Resident #90's Quarterly MDS assessment with an ARD of 11/04/2022 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. Review of Section K-Swallowing/Nutritional Status .Nutritional Approaches revealed Resident #90 was on a mechanically altered diet but was not coded for a therapeutic diet. Review of Resident #90's Active Orders As Of: 01/16/2023 revealed Diet: FMP, Pureed, Nectar Consistency, LCS. active as of 04/30/2022. Review of Resident #90's comprehensive care plan with a revision date of 05/09/2022 revealed Focus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 7 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0657 Level of Harm - Minimal harm or potential for actual harm .has the potential for a nutritional problem r/t protein calorie malnutrition .diet: FMP, pureed diet with nectar thin liquids. Observation on 01/16/2023 at 12:00 p.m. of Resident #90 revealed she was in the dining room and was assisted with eating, her meal ticket read, FMP, Pureed, Nectar Consistency, LCS diet. Residents Affected - Some Interview on 01/18/2023 at 12:40 p.m. with MDS Coordinator B revealed that the comprehensive care plan did not reflect the LCS diet ordered for Resident #90 and that an incorrect diet could result in harm of a resident choking or receiving a diet that could make them ill. Review of the facility policy and procedure titled Comprehensive Care Plan (undated) revealed c. The comprehensive care plan will be reviewed and revised, based on changing goals, preferences and needs of the resident in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 8 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed in that: Residents Affected - Some The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Record review of staff roster, provided by the facility, undated, revealed the staff member was listed as Activities Director. Further review revealed the AD was hired on 07/09/2019. Record review of a document provided by the AD revealed a certificate titled, Modular Education Program for Activity Professionals MEPAP 2nd Edition. Further review revealed the program provided 90 hours of instruction and 90 hours of practicum Advanced Technology Course (Part One of Two Parts) Activity Director Home Study Course, with a start date of 10/28/2017 and completion date of 03/01/2018. Review of Modular Education Program for Activity Professionals, website, https://activityadvisor.org/, on 01/18/2023 revealed the MEPAP course is divided into two parts-MEPAP Part One and MEPAP Part Two. Further review revealed Activity Professional Certified (APC) requires only the MEPAP Part One. Review of National Certification Council for Activity Professionals, website, https://nccap.org/, on 01/18/2023 revealed Certification Renewals: Renewal is required every 2 years. APC: 20 CE (Continuing Education) hours every 2 years. Record review of a certificate of completion provided by the AD revealed the AD completed 8 continuing education hours for Activity Directors on October 2, 2020. During an interview with the HR Manager on 01/18/2023 at 2:05 p.m., the HR Manager was asked for documentation of the AD's certification and any continuing education. The HR Manager stated she and did not have that information on file but called the AD to the office to provide the requested documentation. During an interview with the AD on 01/18/2023 at 2:45 p.m., the AD revealed she became certified in 2018 and completed continuing education to renew in 2020. The AD stated when it was time to renew again in 2022 the facility had positive cases of COVID, and she was not allowed to attend training. During an interview with the Administrator on 01/18/2023 at 3:10 p.m., the Administrator stated she did recall the AD informed her the facility where the continuing education was held had requested staff not attend if they worked in a facility currently caring for COVID positive residents. The Administrator further stated she had thought the AD had looked for some on-line renewal training at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 9 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0680 Level of Harm - Minimal harm or potential for actual harm Record review of the AD's job description provided by the facility revealed a section, Required Education and Experience: Qualified therapeutic recreation specialist or activities professional who is licensed and registered by the State; Certified as a therapeutic recreation specialist or activities professional by a recognized accrediting body. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 10 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 resident (#27) out of 2 residents reviewed for oxygen therapy in that: Residents Affected - Few Resident #27's oxygen setting was on 3L/min when she was prescribed 2L/min. This deficient practice could affect residents who receive oxygen therapy and could result in respiratory distress. The findings were: Review of Resident #27's electronic face sheet dated 01/15/2023 revealed she was admitted to the facility on [DATE] with diagnoses of heart failure (a progressive heart disease that affects the pumping action of the heart muscles), myocardial infarction (damage to the heart muscle caused by a loss of blood supply due to blocks in the arteries), chronic obstructive pulmonary disease, (COPD) (persistent respiratory symptoms like progressive breathlessness and cough) atrial fibrillation (abnormal heart rhythm) and cardiac pacemaker (surgical insertion of a small device under the collarbone to control the electrical events of the heart). Review of Resident #27's Annual MDS assessment with an ARD of 12/17/2022 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact. Resident #29 was not coded to be on oxygen therapy. Review of Resident #27's comprehensive care plan with a revision date of 09/12/2022 revealed under Focus .has oxygen therapy r/t COPD .Interventions .Oxygen settings: The resident has O2 at 2L continuously. Review of Resident #27's Active Orders As Of: 01/16/2023 revealed Continuous O2 at 2L per n/c to maintain O2 sat >92% .with a start date of 09/29/2022. Review of Resideent #27's MAR dated 01/01/2023 to 01/31/2023 reveaeled she had continuous O2 at 2L per n/c initialed off for each day to include 01/15/2023 and 01/16/2023. Observation on 01/15/2023 at 10:56 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/min via nasal cannula. Observation on 01/16/2023 at 09:55 a.m. of Resident #27 revealed she was sitting in her room in her wheel chair and had oxygen infusing at 3L/min via nasal cannula. Observation on 01/16/2023 at 1:00 p.m. of Resident #27 accompanied by LVN A revealed the resident's oxygen concentrator rate setting was 3L/min. LVN C stated the oxygen setting needed to be at 2L/min and that she had not checked it. LVN C stated the correct oxygen rate because too much or too little could cause respiratory distress. Interview on 01/15/2023 at 11:00 a.m. with Resident #27, she stated she was on oxygen continuously (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 11 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0695 since she was admitted to the facility. She stated that only the nurses adjusted the oxygen setting. Level of Harm - Minimal harm or potential for actual harm Interview on 01/18/2023 at 12:58 p.m. with the DON revealed that she knew about Resident #27's oxygen being set on 3L/min instead of 2L/min as ordered, and stated it is our responsibility to monitor that the rate is correct and we make rounds. She stated that a resident with COPD must have the right amount of O2 or could be harmed. Residents Affected - Few Review of the facility policy and procedure titled General Guidelines for Medication Administration dated 09-2018 revealed Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer .Medications are administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 12 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews and record reviews, the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication cart checked (Hall 600) out of 4 medication carts checked for storage practices in that: 1 bottle of Dermarite Proheal Liquid Protein (A medical food developed for the dietary management of wounds and conditions requiring supplemental protein) had an opened date of 11/17/2022 written on it and 1 bottle of Nutricia Uti-Stat (a ready to drink medical food providing cranberry concentrate with added nutrients) had an opened date of 10/06/2022 written on it and both had passed the manufacturer discard dates after opening were located inside the 600 Hall medication cart This deficient practice could affect residents who receive medications with manufacturers recommendations for discard after opening and could result in diminished effectiveness. The findings were: Observation on 01/16/2023 at 1:50 p.m. with LVN D, checked medication storage for the 600 Hall medication cart and one bottle of Dermarite Proheal Liquid Protein labeled with an opened date of 11/17/2022. The bottle had manufacturers recommendations listed on the back of the label: Discard 60 days after opening. One bottle of Nutricia Uti-Stat had an opened date of 10/6/2022 with manufacturers recommendations listed on the back of the label Discard 3 months after opening. Interview on 1/16/2023 at 2:00 p.m. with LVN D revealed it is important to follow manufacturer's recommendations because the effectiveness of the medicated solution could decrease and not provide the desired effects. He stated that pharmacy checks the medication carts and the nurses, and he did not realize the solutions had recommended discard dates after being opened. Interview on 01/18/2023 at 12:58 p.m. with the DON revealed she was informed the solutions were expired and she contacted the pharmacist that had just been at the facility two weeks prior to do medication cart audits about the expiration date requirements and the Pharmacist confirmed the solutions were out of date with the manufacturer's recommendations. She stated that harm of taking the protein solution after the discard date was it could cause a resident to have nausea and vomiting. Review of the facility policy and procedure titled Storage of Medications (undated) revealed Ensure that medications are stored in a safe, secure and orderly manner .no discontinued, outdated or deteriorated medications are to be used for use in this facility. All such medications are destroyed according to facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 13 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 3 of 10 dietary aides (Dietary Aide H, Dietary Aide I, and Dietary Aide J) reviewed for competencies, in that: The facility failed to ensure Dietary Aide H, Dietary Aide I and Dietary Aide J had a Food Handling Certificate prior to working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. The findings were: Record review of the facility staff roster, undated, revealed Dietary Aide H was a full-time dietary aide with a hire date of 01/11/2023. Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide H completed the Texas Food Handler Training Certificate Program on 01/17/2023, after surveyor requested dietary staff credentials on 01/15/2023. Record review of the facility staff roster, undated, revealed Dietary Aide I was a full-time dietary aide with a hire date of 06/14/2021. Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide I completed the Texas Food Handler Training Certificate Program on 01/16/2023, after surveyor requested dietary staff credentials on 01/15/2023. Record review of the facility staff roster, undated, revealed Dietary Aide J was a part-time dietary aide with a hire date of 12/16/2022. Record review of dietary staff credentials provided by the Food Service Supervisor revealed Dietary Aide J completed the Texas Food Handler Training Certificate Program on 01/16/2023, after surveyor requested dietary staff credentials on 01/15/2023. During an interview with the Food Service Director on 01/18/2023 at 1:45 p.m., the Food Service Director confirmed she had not provided the certificates upon initial request but had them now. The FSS further stated Dietary Aide H and Dietary Aide J were new employees and that Dietary Aide I had recently transferred to dietary from the housekeeping department. During an interview with the HR Manager on 01/18/2023 at 2:00 p.m., the HR Manager revealed Dietary Aide I had transferred from the housekeeping department to dietary on 12/16/2022. During an interview with the Administrator on 01/18/2023 at 4:05 p.m., the Administrator stated Dietary Aide I had filled in during a brief time in the kitchen and decided she liked that department and put in for a request. The Administrator further stated dietary staff are required to have a Food Handler's Certificate prior to working in the kitchen and confirmed the certificates for Dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 14 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0802 Aide H, Dietary Aide I and Dietary Aide J were dated after surveyor request on 01/15/2023. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's job description, Dietary Aide, undated, revealed, Required Education and Experience: Food Handler certification pursuant to requirements by the State. Residents Affected - Some Record review of the facility's policy, Dietary Staffing, undated, revealed, Ensure there is sufficient and qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 15 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 - Potential for minimal harm Residents Affected - Many 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 follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must 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, in that: The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2022. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's staff roster, undated indicated the following: 1 Administrator 5 RNs (included DON and 1 MDS Coordinator) 25 LVNs (included 2 ADONs, 1 MDS Coordinator and 1 Treatment Nurse) 42 CNA/CMAs (included 4 Caregivers) 3 Maintenance Personnel 12 Housekeeping/Laundry Personnel 14 Dietary Personnel 18 Therapy Personnel (included 2 Restorative Aides) 2 Social Work Personnel 2 Activity Directors 8 Security/Screener Personnel 6 Office Staff Personnel Record review of the facility CMS form 672 (Resident Census and Conditions of Residents) dated 01/15/2023 provided by MDS Coordinator A indicated a total of 99 residents in the facility. Record review of the PBJ Staffing Data Report, FY Quarter 4 2022 (July 1 - September 30), dated 01/11/2023, revealed the facility had failed to submit data for the quarter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 16 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 - Potential for minimal harm Residents Affected - Many During an interview with the Administrator on 01/18/2023 at 3:20 pm, the Administrator revealed the Payroll Based Journal staffing hours are submitted by the corporate office. The Administrator further revealed the corporate office staff are able to pull directly from our time clocks and submit electronically. During an interview with the Administrator on 01/18/2023 at 4:20 pm, the Administrator stated they did not have a policy regarding submitting the Payroll Based Journal. The Administrator stated the corporate office had informed her we report as required by CMS and provided a copy of the PBJ Policy Manual. Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, revealed Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 4 date range as July 1-September 30. Policy manual revealed, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 17 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 Provide and implement an infection prevention and control program. 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 maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #92) reviewed for infection control, in that: Residents Affected - Few While providing incontinent care for Resident #92 CNA F did not wash or sanitize her hands between change of gloves before touching the resident's clean brief and after cleaning the resident's buttocks' area. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #92's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating severe cognitive impairment. Resident #92 required extensive assistance, was occasionally incontinent of bladder and frequently incontinent of bowel. Observation on 01/17/23 at 10:15 a.m. revealed during incontinent care, after cleaning Resident #92's buttocks , CNA F changed her pair of gloves but did not sanitize her hands. The resident had had a bowel movement. CNA F, then, applied clean briefs to the resident and fastened them. During an interview with CNA F on 01/17/2023 at 10:25 a.m., the CNA verbally confirmed not washing or sanitizing her hands. She confirmed receiving infection control in service multiple times in the last year. She forgot to wash her hands. During an interview with the DON on 01/18/2023 at 10:30 a.m., the DON verbally confirmed the staff needed to sanitize their hands between change of gloves. The staff was trained multiple times a year on infection control and they did return demonstration with skill checks. The DON agreed it was a risk for infection for the resident. Review of CNA F's Certified nurse aide proficiency audit, dated 07/06/2022 revealed CNA F received proficiency for perineal care and infection control. Review of facility's policy, titled Hand Hygiene , undated, revealed Hands should be washed for 20 seconds using soap and water under the following conditions: [ .] i. after contact with blood, body fluids, excretions, secretions, mucous membrane or non intact skin, [ .] l. before putting on gloves, m. after removing gloves FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 18 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain spaces of at least 80 square feet per resident for 13 (resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, and 407) of 34 Resident rooms inspected for resident room sufficient space for privacy and comfort, in that: The facility failed to ensure resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404, 405, 406, and 407 were maintained with at least 80 square feet of space per resident. This failure could place residents at risk of restricting their resident rights for comfort and privacy. The findings were: Record review of the Bed Classification Form 3740 dated 01/15/2023 which was filled out by the Administrator indicated the capacity of the facility was 144 beds. In an interview with the Administrator on 01/17/2023 at 3:00 p.m., the Administrator revealed she was not aware of any room waivers for the facility. The Administrator stated the bed classification was accurate and further stated even though some of the rooms were currently being used as private rooms her understanding was, they could be used as semi-private if needed. In an interview with the Administrator on 01/18/2023 at 9:35 a.m., the Administrator stated her Maintenance Director would measure the rooms to ensure they meet regulations. Review of the measurements provided by LSC, of the bedrooms which were measured and identified by the Maintenance Director indicated as follows: Bedroom # (allocated for 2 Beds as per Form 3740) 101 - 78.32 square feet per bed 102 - 76.69 square feet per bed 103 - 78.325 square feet per bed 104 - 77.255 square feet per bed 105 - 77.05 square feet per bed 106 - 75.31 square feet per bed 107 - 78.31 square feet per bed 401 - 78.88 square feet per bed 403 - 71.62 square feet per bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 19 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0912 404 - 76.18 square feet per bed Level of Harm - Minimal harm or potential for actual harm 405 - 77.17 square feet per bed 406 - 73.05 square feet per bed Residents Affected - Some and room [ROOM NUMBER] (allocated for 3 beds as per Form 3740) 407 - 48.51 square feet per bed (LSC observation showed only 2 bed allocation based on 2 overbed lights and 2 nurse call fixtures) In an interview with the Administrator on 01/18/2023 at 4:30 p.m., the Administrator stated she could not find any documentation for room waivers and would contact her corporate office for further assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 20 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0941 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to provide effective communications mandatory training for 21 of 21 employees (Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training, in that: The facility failed to ensure effective communication training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. The findings were: Review of Facility Staff Roster, undated, revealed: Administrator - date of hire - 01/31/2022 DON - date of hire - 07/06/2022 AD - date of hire - 07/09/2019 FSS - date of hire - 02/09/2014 PT - date of hire - 01/01/2020 OT - date of hire - 01/01/2020 ST - date of hire - 03/18/2020 ADON K - date of hire - 09/19/2019 ADON L - date of hire - 04/26/2022 SW M - date of hire - 03/01/2022 CNA N - date of hire - 04/16/2020 CNA O - date of hire - 01/11/2019 CNA P - date of hire - 07/09/1996 CNA Q - date of hire - 01/24/2014 CNA R - date of hire - 08/02/1995 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 21 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0941 CNA S - date of hire - 01/27/1983 Level of Harm - Minimal harm or potential for actual harm CNA T - date of hire - 03/30/2020 LVN U - date of hire - 06/25/2021 Residents Affected - Many LVN V - date of hire - 01/07/2019 RN W - date of hire - 11/24/2015 LVN X - date of hire - 06/24/2020 During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received communication training. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed. During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware communication was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff. Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 22 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 4 of 21 employees (CNA N, CNA R, RN W and LVN X) reviewed for training, in that: The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA N, CNA R, RN W and LVN X. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings were: Review of Facility Staff Roster, undated, revealed: CNA N - date of hire - 04/16/2020 CNA R - date of hire - 08/02/1995 RN W - date of hire - 11/24/2015 LVN X - date of hire - 06/24/2020 During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed CNA N, CNA R, RN W and LVN X had not received training in resident rights. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed. During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware resident rights was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff. Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 23 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 21 of 21 employees (the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, undated, revealed: Administrator - date of hire - 01/31/2022 DON - date of hire - 07/06/2022 AD - date of hire - 07/09/2019 FSS - date of hire - 02/09/2014 PT - date of hire - 01/01/2020 OT - date of hire - 01/01/2020 ST - date of hire - 03/18/2020 ADON K - date of hire - 09/19/2019 ADON L - date of hire - 04/26/2022 SW M - date of hire - 03/01/2022 CNA N - date of hire - 04/16/2020 CNA O - date of hire - 01/11/2019 CNA P - date of hire - 07/09/1996 CNA Q - date of hire - 01/24/2014 CNA R - date of hire - 08/02/1995 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 24 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0944 CNA S - date of hire - 01/27/1983 Level of Harm - Minimal harm or potential for actual harm CNA T - date of hire - 03/30/2020 LVN U - date of hire - 06/25/2021 Residents Affected - Many LVN V - date of hire - 01/07/2019 RN W - date of hire - 11/24/2015 LVN X - date of hire - 06/24/2020 During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received training in the QAPI program. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed. During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware QAPI was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff. Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 25 of 30 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 675469 B. Wing (X3) DATE SURVEY COMPLETED A. Building 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0945 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 7 of 21 staff (CNA N, CNA P, CNA Q, CNA R, CNA S, CNA T and LVN V) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to CNA N, CNA P, CNA Q, CNA R, CNA S, CNA T and LVN V. This failure could place residents at risk of illness due to lack of staff training. The findings were: Review of Facility Staff Roster, undated, revealed: CNA N - date of hire - 04/16/2020 CNA P - date of hire - 07/09/1996 CNA Q - date of hire - 01/24/2014 CNA R - date of hire - 08/02/1995 CNA S - date of hire - 01/27/1983 CNA T - date of hire - 03/30/2020 LVN V - date of hire - 01/07/2019 During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed CNA N, CNA P, CNA Q, CNA R, CNA S, CNA T and LVN V had not received infection prevention and control training. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed. During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she would follow up on the training that was missing. Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. Procedure: 8. Continuing education will include the following topics: .n. Infection control and prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 26 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0946 Provide training in compliance and ethics. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide the required compliance and ethics training for 21 of 21 employees (the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training requirements, in that: Residents Affected - Many The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The findings were: Review of Facility Staff Roster, undated, revealed: Administrator - date of hire - 01/31/2022 DON - date of hire - 07/06/2022 AD - date of hire - 07/09/2019 FSS - date of hire - 02/09/2014 PT - date of hire - 01/01/2020 OT - date of hire - 01/01/2020 ST - date of hire - 03/18/2020 ADON K - date of hire - 09/19/2019 ADON L - date of hire - 04/26/2022 SW M - date of hire - 03/01/2022 CNA N - date of hire - 04/16/2020 CNA O - date of hire - 01/11/2019 CNA P - date of hire - 07/09/1996 CNA Q - date of hire - 01/24/2014 CNA R - date of hire - 08/02/1995 CNA S - date of hire - 01/27/1983 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 27 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0946 CNA T - date of hire - 03/30/2020 Level of Harm - Minimal harm or potential for actual harm LVN U - date of hire - 06/25/2021 LVN V - date of hire - 01/07/2019 Residents Affected - Many RN W - date of hire - 11/24/2015 LVN X - date of hire - 06/24/2020 During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received compliance and ethics training. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed. During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware ethics was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff. Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. Procedure: 8. Continuing education will include the following topics: .i. Ethical issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 28 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0949 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide effective behavioral health mandatory training for 21 of 21 employees (Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: Review of Facility Staff Roster, undated, revealed: Administrator - date of hire - 01/31/2022 DON - date of hire - 07/06/2022 AD - date of hire - 07/09/2019 FSS - date of hire - 02/09/2014 PT - date of hire - 01/01/2020 OT - date of hire - 01/01/2020 ST - date of hire - 03/18/2020 ADON K - date of hire - 09/19/2019 ADON L - date of hire - 04/26/2022 SW M - date of hire - 03/01/2022 CNA N - date of hire - 04/16/2020 CNA O - date of hire - 01/11/2019 CNA P - date of hire - 07/09/1996 CNA Q - date of hire - 01/24/2014 CNA R - date of hire - 08/02/1995 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 29 of 30 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 675469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Floresville 1811 Sixth St Floresville, TX 78114 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 0949 CNA S - date of hire - 01/27/1983 Level of Harm - Minimal harm or potential for actual harm CNA T - date of hire - 03/30/2020 LVN U - date of hire - 06/25/2021 Residents Affected - Many LVN V - date of hire - 01/07/2019 RN W - date of hire - 11/24/2015 LVN X - date of hire - 06/24/2020 During a record review and interview with the HR Manager on 01/18/2023 at 2:15 p.m., the HR Manager reviewed the training spreadsheet and confirmed the Administrator, DON, AD, FSS, PT, OT, ST, ADON K, ADON L, SW M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN V, RN W and LVN X had not received training in behavioral health. The HR Manager stated training was a team effort however it is her responsibility to keep a spread sheet to track which training each employee has taken and when it was completed. During an interview with the Administrator on 01/18/2023 at 4:10 p.m., the Administrator stated she was not aware behavioral health was part of the mandatory training. She stated she will ensure it is added to the list of required training for staff. Record review of the facility's policy titled, Ongoing Staff Training, undated, revealed, Purpose: Provide on-going education for all staff to ensure proficiency and competency. Procedure: 8. Continuing education will include the following topics: .b. Behavioral issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675469 If continuation sheet Page 30 of 30