Inspection visit
Inspection
18 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 18 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the recommendations from the PASARR level II
determination and the PASARR evaluation report were included into a resident's assessment, care
planning, and transitions of care for 1 (Resident #5) of 3 residents reviewed for PASARR services, in that:
Resident #5 did not receive specialized PASRR services as agreed upon during his Interdisciplinary Team
meeting.
This failure could place residents with a positive PASRR evaluation at risk for the loss of opportunity to
reach their highest level of functioning and could contribute to a decline in physical, mental, and
psychosocial well-being.
The findings were:
Record review of Resident #5's face sheet, dated 02/15/2024, revealed the resident was admitted to the
facility on [DATE] with diagnoses including Hypertensive Heart Disease Without Heart Failure, Other
Developmental Disorders of Scholastic Skills, and Anxiety Disorder.
Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated
intact cognition.
Record review of Resident #5's care plan, revised 12/12/2023, revealed [Resident #5] is PASRR positive d/t
[due to] OTHER DEVELOPMENTAL DISORDERS OF SCHOLASTIC SKILLS .
Further review revealed, 9/19/23 Quarterly [Interdisciplinary Team] meeting . Start: Behavioral Support and
[physical therapy/occupational therapy/speech therapy] thru Habilitative services.
During an interview with the DOR on 02/14/2024 at 2:40 p.m., the DOR stated that Resident #5 had not
received habilitative physical therapy, occupational therapy, or speech therapy since 01/04/2024 because
the request for reimbursement had not yet been approved.
During an interview with the DON on 02/16/2024 at 2:30 p.m., the DON confirmed Resident #5 had not
received habilitative physical therapy, occupational therapy, or speech therapy since 01/04/2024 and
confirmed the resident may experience a functional decline as a result.
Record review of the facility policy, PASRR, undated, revealed, .the Facility collaborates with local
resources when special services are necessary or required.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 18
Event ID:
675469
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
02/16/2024
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 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure each resident with a mental disorder was screened
prior to admission for 1 of 3 of (#2) residents reviewed for PASRR:
Residents Affected - Few
The facility did not correctly identify Resident #2 on the PASRR Level 1 Screening Form as having Mental
Illness and did not submit a request to correct their PASRR negative screening.
This failure could affect residents with mental illness that was not considered to be a Positive PASRR and
could result in a decrease in services.
The Findings were:
Record review of Resident #2's Face sheet, dated 02/14/2024, revealed an [AGE] year-old, admitted on
[DATE] and was diagnosed with schizoaffective [a condition where symptoms of both psychotic and mood
disorders are present together during one episode], bipolar [causes extreme mood swings that include
emotional highs (mania or hypomania) and lows] and [Type two Diabetes] health condition that affects how
your body turns food into energy.
Record review of Resident #2's Quarterly MDS dated [DATE] section I Active Diagnoses, psychiatric/mood
disorder revealed a diagnosis of schizoaffective disorder / bipolar disorder.
Record review of Resident # 2 quarterly MDS dated [DATE] revealed a BIMS score of 10, indicating
cognition was moderately impaired.
Record review of Resident # 2's physician orders for February 2024, revealed an order for Depakote
Sprinkles 125 mg daily for schizophrenia.
Record review of Resident # 2's care plan dated 5/11/22 revealed care plan Behavior problem
Schizophrenia interventions Administer medication as ordered.
Record review of Resident #2's PASSR (Preadmission Screening & Resident Review) Level one, prior to
this SNF, dated 7/1/2022, was positive for Mental Illness.
Interview on 02/14/2024 at 1:58 PM with the MDS Nurse revealed when asked if she knew that Resident #2
diagnosis of schizoaffective and bipolar disorder should trigger a positive PASRR screening, she responded
that she was not aware that she probably inputted the wrong PL 1 information and would correct the
mistake at this time. She noted that by this information not being reported accurately, residents risked
possibly not receiving the services needed.
Interview on 02/14/2024 at 3:58 PM with the DON stated the MDS nurse was responsible for residents with
positive PASRR. The DON stated if PASSR was not completed correctly, it could affect the resident by not
receiving services.
Record review of the Policy PASRR (preadmission and screening resident review), undated, revealed, If the
PASSR Level 1 screening indicates the individual may have an ID, DD or MI diagnosis, follow the state
specific process for completion of the level II evaluation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 2 of 18
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
02/16/2024
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
Based on interviews and record reviews, the facility failed to complete the baseline care plan for 1 of 32
residents (Resident #153) reviewed for baseline care plans in that:
Residents Affected - Few
The facility failed to complete (Resident # 153's) baseline care plan within the required time frame.
This deficient practice could affect residents who receive care at the facility and could result in missed or
inadequate care.
The findings were:
Record review of Resident #153's face sheet dated 02/15/24 with recent admission date of 2/2/24 and
diagnoses which included: displaced fracture of the left femur (a left broken thighbone), type 2 diabetes (a
condition in which the body has difficulty controlling blood sugar) and atherosclerotic heart disease (an
illness in which the heart's arteries are damaged).
Record review of Resident #153's MDS, completed on 2/10/24, revealed a BIMS score of 10, which
indicated moderate cognitive impairment.
Record review of Resident #153's Baseline Care Plan, shows a completion date of 2/7/24 with a locked
finalization date of 2/13/24.
In an interview with MDS Coordinator B on 02/15/24 at 1:45 p.m., confirmed that the baseline care plan for
Resident # 153 was not done within the required time frame of 48 hours after admission.
In an interview with the ADON on 2/15/24 AT 2:00 p.m., stated that the time frame for completion of the
baseline care plan for Resident # 153 was not met. She stated that the baseline care plans were usually
completed by the charge nurses. She stated that the completion of the baseline care plan would help staff
to understand what is going on with the resident's condition.
In an interview with the DON on 2/15/24 at 2:20pm confirmed that the baseline care plan for Resident #
153 did not meet the necessary time frames for completion.
Review of the facility policy and procedure titled, Care Plans-Baseline, (undated), revealed, A baseline plan
of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48)
hours of admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 3 of 18
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
02/16/2024
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews the facility failed to develop and implement a comprehensive
person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a
resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive
assessment for 2 of 8 residents (Residents #82 and #92) reviewed for care plans, in that:
1. The facility failed to care plan Resident #82's self-care for colostomy.
2. The facility failed to ensure Resident #92's indwelling catheter was free of kinks; a dignity bag and anchor
were used.
These failures could have placed residents at risk of not having their needs met.
The findings were:
1. Record review of Resident #82's face sheet, dated 2/13/24, revealed an admission date of 10/2/23 with
the diagnosis that included: [Candidiasis] a fungal infection caused by a yeast, [colostomy status] An
opening into the colon from the outside of the body which provides a new path for waste material to leave
the body after part of the colon has been removed, and [Bladder dysfunction] is the leaking of urine that
you can't control.
Record review of Resident's #82's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which
indicated intact cognition.
Record review of Resident's #82's Quarterly MDS, dated [DATE], revealed under section H Bowel and
Bladder section C selected indicating colostomy staus.
Record review of Resident #82's Physician Orders for February 2024 revealed an order for, Change
colostomy bag every three days and PRN (as needed).
Record review of Resident #82's (TAR) Treatment administration record for February 2024 revealed staff
nurse was signing TAR and was not completing the treatment.
During an interview with Resident #82 on 2/15/24 at 1:35 p.m., the resident revealed he was educated on
colostomy care at [Name of Hospital] and completed his own colostomy care at the facility.
During an interview with RN C on 2/15/24 at 1:44 p.m., RN C stated Resident # 82 completed his own
colostomy care and she signs the TAR as per the facility culture, and she had not been trained otherwise.
2. Record review of resident #92's face sheet, dated 2/15/2024, revealed the resident was initially admitted
to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: encephalopathy (damage
or disease that affects the brain), cognitive communication deficit, dysphagia (swallowing difficulties),
chronic kidney disease and dementia.
Record review of Resident #92's MDS, dated [DATE], revealed the resident had a BIMS score of 04,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 4 of 18
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
02/16/2024
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 0656
Level of Harm - Minimal harm
or potential for actual harm
which indicated severe cognitive impairment. Further review revealed the resident had an indwelling
catheter.
Record review of Resident #92's Comprehensive Care Plan, dated 12/07/2023, revealed, Check tubing for
kinks each shift.
Residents Affected - Few
Observation on 2/15/2024 at 8:17 a.m. revealed there was not a dignity bag or anchor on Resident #92's
catheter bag and the resident's catheter bag was stuffed between his left hip and wheelchair.
During an interview with the DON on 2/15/24 at 210 p.m., the DON stated the care plans were Residents
#82 and #92 were not being updated to reflect to indicate Resident #82 did his own colostomy care, and
there was no anchor on foley catheter for Resident #92 risked not all team members being aware of the
residents needs. The DON further stated she was unaware Resident #82 was completing his colostomy
care. The DON stated she was unaware Resident #92 did not have an anchor on their foley catheter.
Record review of the facility's policy titled, Comprehensive Care Planning, undated, revealed, The facility
will develop and implement a comprehensive person-centered care plan for each resident, consistent with
the residents rights that includes measurable objectives and time frames to meet a residence medical,
nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . when
developing the comprehensive care plan, facility staff will, at a minimum, use the minimum data set to
assess the residents clinical condition, cognitive and functional status, and use of services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 5 of 18
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
02/16/2024
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 - Few
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 09/21/23.
During an interview with the Activities Director on 02/15/24 at 10:45a.m., she stated that she was hired on
9/21/23 as an Activity Director Assistant but became Director of the Activity Department on 12/1/23. She
stated that she knows the position requires an Activity Director certification and did not have the
certification. She planned on enrolling this week in an on-line certified Activity Director course. She stated
that being a certified activity director would have helped her better understand how to work with Residents
with a diagnosis of dementia.
During an interview with the Administrator on 2/15/24 at 12:00 noon stated that she understood that the
activity director position required an activity director certification based on completion of a certified activity
director course and that the current Activity Director did not have the required certification for the position.
During an interview with the Human Resources Director on 2/15/24 at 1:15 p.m., stated that she is
responsible for ensuring that the Activity Director had obtained an Activity Director certification and that the
current Activity Director was not certified for her position. She confirmed that the Activity Director would
enroll in an on-line course Activity Director certification course in the immediate week.
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 the facility's Employee Handbook provided by the HR Director that is undated stated on
page 7 that All employees must have the credentials for their specific jobs. This may include certification,
licensure, or registration.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 6 of 18
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
02/16/2024
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to ensure incontinent bladder residents
received appropriate treatment and services to prevent urinary tract infections and restore continence to
the extent possible for 2 of 12 residents (Residents #82 and #7) reviewed for indwelling catheters and
perineal/incontinent care, in that:
1. The facility failed to ensure Resident #82 indwelling catheter was attached to prevent pulling or tugging to
the urethra.
2. The facility failed to ensure Resident #7's indwelling catheter was attached to prevent pulling or tugging
to the urethra and failed to provide a dignity bag.
These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine
is transported out of the body from the bladder), and urinary tract infections due to improper care.
The findings were:
1. Record review of Resident #82's face sheet, dated 2/13/24, revealed an admission date of 10/2/23 with
the diagnosis that included: [Candidiasis] a fungal infection caused by yeast, [colostomy status] an opening
into the colon from the outside of the body provides a new path for waste material to leave the body after
removing part of the colon, and [Bladder dysfunction] is the leaking of urine that you can't control.
Record review of Resident's #82's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which
indicated intact cognition, and under section H Bowel and Bladder, an indwelling catheter was selected.
Record review of Resident #82's care plan, dated 10/23/23, revealed the resident's care plan addressed the
resident's urinary catheter with interventions, Use stabilizer or secure device.
During an observation on 02/15/24 at 9:47 a.m. revealed Resident #82 had an indwelling foley catheter
without a secure device.
During an interview with Resident #82 on 02/15/24 at 10:45 a.m., the resident stated, They never give me
that thing to keep this from pulling out.
During an interview with RN C on 02/15/24 at 11:30 a.m., RN C stated she was the nurse for Resident #82
and confirmed the resident was supposed to be wearing a secure device to prevent the urinary catheter
from pulling on the resident's urethra. RN C stated she did not know why Resident #82 was not wearing a
secure device but lack of wearing an [NAME] he risked having foley catheter pulled.
During an interview with the DON on 02/15/24 at 2:35 p.m., the DON stated Resident #82 should have
been wearing a secure device to prevent the urinary catheter from possibly dislodging. The DON stated it
was her expectation that all residents with a urinary catheter wore a secure device to prevent the catheter
from pulling or possibly becoming dislodged.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 7 of 18
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
02/16/2024
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
2. Record review of Resident #7's face sheet, dated 2/15/2024, revealed the resident was initially admitted
to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: hypotension (low blood
pressure), neuromuscular dysfunction of the bladder (nerves and muscles on't work together very well),
bladder-neck obstruction, and dementia.
Record review of Resident #7's MDS, dated [DATE], revealed the resident had a BIMS score of 08, which
indicated moderate cognitive impairment.
Record review of Resident #7's Comprehensive Care Plan, dated 10/24/2023, revealed a focus area
related to the resident's catheter dignity bag.
Record review of Resident #7's orders revealed, Ensurelegstrap/securementdevice and dignity bag
tocatheter tubing in place
During an observation on 2/15/2024 at 8:15 a.m. revealed Resident #7's catheter was hanging on the side
of the bed with no dignity bag and not secured to prevent pulling or tugging.
Record review of the facility's policy titled, Catheter Care, Urinary, undated, revealed, Ensure that catheter
remains secured with a leg strap.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 8 of 18
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
02/16/2024
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure each resident's drug regimen was free from
unnecessary medications (excessive dose and duplicative therapy) for 1 of 6 residents (Resident #6)
reviewed for unnecessary medications, in that:
Residents Affected - Few
1. Resident #6 received Lorazepam 0.5 mg three times a day for general anxiety disorder.
2. Resident #6 received Buspirone 7.5 mg three times a day for general anxiety disorder
This failure could place residents at risk for adverse drug consequences and receiving unnecessary
medications.
The findings were:
Record review of Resident #6's Face sheet, dated 2/15/24, revealed the resident was admitted to the facility
on [DATE] with diagnoses that included: [Generalized anxiety disorder] involves a persistent feeling of
anxiety or dread, which can interfere with daily life, [ Major depressive disorder] mood disorder that causes
a persistent feeling of sadness and loss of interest, and [Heart failure] occurs when the heart muscle
doesn't pump blood as well as it should.
Record review of Resident #6's Quarterly MDS Assessment , dated 10/20/23, revealed the resident had a
BIMS score of 4, which indicated severe cognitive impairment.
Record review of Resident # 6 's comprehensive physician orders, dated 2/14/24, revealed orders for:
- Lorazepam 0.5 mg three times a day orally for general anxiety disorder. There was no documentation
indicating the need for duplication of therapy. Further review revealed Resident #6 had been on the
medication since 1/29/24.
- Buspirone 7.5 mg three times a day orally for general anxiety disorder. There was no documentation
indicating the need for duplication therapy. Further review revealed Resident # 6 had been on medication
since 1/28/24.
Record review of Resident #6's comprehensive care plan, dated 2/14/24, revealed a care plan for Anxiety
with interventions to administer medications as ordered.
Record review of Resident #6's Medicaion Adminstration Record for Febuary 2024 revealed the resident
had received Lorazepam and Buspirone three times a day.
Record review of Resident #6's Pharmacy Consultant's Drug Regimen Reviews, from 01/01/24 to 02/01/24,
revealed there was no recommendation for Lorazepam or Buspirone found indicating an issue.
During an interview with the DON on 02/15/2024 at 1:18 p.m., the DON stated she was unaware Resident
#6 was on Lorazepam 0.5 mg three times a day and Buspirone 7.5 mg three times for anxiety. The DON
stated these medications could be considered as duplication of therapy and could cause possible side
effects when used concurrently. The DON stated the facility did not have a policy to address this
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 9 of 18
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
02/16/2024
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 0757
issue.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 10 of 18
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
02/16/2024
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the
facility were labled and stored in loccked compartments in 1 medication cart of 6 medication carts (Nurse's
Cart 400-hallway) and one crash cart of 2, reviewed for medication storage, in that:
1. The facility failed to ensure the Nurse's Cart 400 hallway was left unlocked and unattended in the hallway.
2. The facility failed to ensure the irrigation solution in the crash cart for the south building was not expired.
These deficient practices could place residents at risk of medication misuse or drug diversion.
The findings included:
1. During an observation on [DATE] at 7:02 a.m., the nurse's treatment cart in the 400 hallway was
unlocked and unattended. There were ambulatory residents in the immediate vicinity, and there were no
nurses at the nurses' station.
During an observation and interview on [DATE] at 7:18 a.m., the treatment cart in the 400 hallway remained
unlocked; RN C was notified that the cart was locked, and she said the cart should not have been unlocked
and it was the responsibility of the nurse working on the cart to ensure a cart is locked when unattended.
She added it was facility policy that medication carts be locked when unattended. RN C said it was
important the medication carts were locked when unattended because the facility had residents who
wandered and could get into them and access the medications.
During an interview on [DATE] at 11:30 a.m., The DON said all employees were responsible for ensuring
medication carts were locked when unattended. The DON stated it was the facility policy that
medication/treatment carts were locked when not attended. She added it was important that medication
carts were locked when not attended by a nurse or medication aide because someone could get into and
take something they were not supposed to. She also stated that the facility had residents with dementia
who could get into things.
2. During an observation on [DATE] at 10:50 a.m., the crash cart in the south building had an expired
irrigation solution.
During an interview on [DATE] at 10:53 a.m. with LVN E, she stated the solution should have been taken
out as it could not work as intended due to it being expired.
Record review of the facility's policy titled, Security of Medication Cart, undated, revealed, The Nurse must
secure the medication cart during the medication pass to prevent unauthorized entry.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 11 of 18
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
02/16/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in
accordance with professional standards for food service safety for 1 of 1 kitchen, in that:
1. Dietary Aide A was not properly wearing a hair restraint.
2. A food item in the dry storage area was not properly dated and labeled.
3. A kitchen drawer had a drawer cover and a drawer surface area that were not cleaned.
These deficient practices could place residents who received meals and snacks from the kitchen at risk for
food borne illness from improper infection control, from a lack of food label date monitoring, and improper
sanitation in the kitchen area.
The findings included:
Observation on 02/13/2024 from 9:50 a.m. to 11:00 a.m. during the kitchen tour revealed the following:
a. Dietary Aide A was working in the kitchen wearing a hair restraint that did not fully cover the back of her
head with visible exposed hair.
b. There was a package of 24 blueberry muffins with a sealed plastic cover in the dry storage area that was
not dated or labeled.
c. There was a kitchen drawer in the general kitchen service area which measured 16 x 5 inches that was
missing a drawer cover.
d. There was a kitchen drawer in the general kitchen service area which measured 35 x 17 inches which
was covered with dirt particles on the service of the drawer which contained two boxes of jelly packets.
During an interview with the Dietary Aide A, during the kitchen tour, on 02/13/24 from 9:50 a.m. to 11:00
a.m., Dietary Aide A stated she usually wore a hair [NAME] under her hair restraint to help keep her hair in
place but she had forgotten to wear it.
During an interview with the Dietary Manager during the kitchen tour on 02/13/24 from 9:50 a.m. to 11:00
a.m., the Dietary Manager stated Dietary Aide A not wearing hair restraint properly could allow hair
particles to fall on the food preparation area. The Dietrary Manager stated he was responsible for ensuring
the food items in dry storage were dated and labeled. The Dietrary Manager further stated the blueberry
muffins were being served the previous day and that dating and labeling the food item would prevent staff
from using the product after the expiration date. The Dietrary Manager stated the kitchen drawer should
have been repaired with a drawer cover for sanitation purposes and the kitchen drawer surface area should
have been cleaned. The Dietrary Manager stated he could not advise when the drawer surface area was
last cleaned.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 12 of 18
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
02/16/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview with the Administrator on 2/15/24 at 9:05 a.m., the Administrator stated staff properly
wearing their hair restraints in the kitchen prevents hair particles from falling onto the food, that dating and
labeling food products prevents them from being served after their expiration date, and that general kitchen
cleaning was necessary for kitchen sanitation.
Record review of the facility's policy titled, Employee Sanitation, dated 10/1/18, revealed, Hair nets or other
effective hair restraints must be worn to keep hair from food and food-contact surfaces.
Record review of the facility's policy titled, Food Storage, dated 10/1/18, revealed, All containers must be
labeled and dated.
Record review of the facility's policy titled, General Kitchen Sanitation, dated 10/1/18, revealed, Clean
non-food-contact surfaces of equipment as necessary to keep them free of dust, dirt, and food particles and
otherwise in a clean and sanitary condition.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS,
revealed. 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in
a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 13 of 18
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
02/16/2024
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the residents' records were complete and accurate
for 3 of 32 residents (Resident #5, #73, and #82) reviewed for clinical records, in that:
1. Resident #5's clinical record included a progress note which was inaccurate and appeared to have been
written about a different resident.
2. Resident #73's diagnosis of Bipolar Disorder was not included on her face sheet.
3. Resident #82's colostomy care was completed by the resident not nursing staff, but nurses were signing
off on the TAR as if they were completing care.
These deficient practices could result in inadequate care due to incomplete and inaccurate medical
records.
The findings were:
1. Record review of Resident #5's face sheet, dated 02/15/2024, revealed the resident was admitted to the
facility on [DATE] with diagnoses including Hypertensive Heart Disease Without Heart Failure, Other
Developmental Disorders of Scholastic Skills, and Anxiety Disorder.
Record review of Resident #5's Quarterly MDS assessment, dated 01/15/2024, revealed a BIMS score of
15 which indicated intact cognition. Further review revealed the resident was a male who utilized a walker
for mobility.
Record review of Resident #5's care plan, revised 12/12/2023, revealed [Resident #5] is PASRR positive d/t
[due to] OTHER DEVELOPMENTAL DISORDERS OF SCHOLASTIC SKILLS . Further review revealed the
resident was able to make his needs known and frequently participates with facility activities.
Record review of Resident #5's clinical record revealed a progress note, dated 5/27/2023, revealed a note
which read, Resident utilizes a wheelchair for mobility. Staff assist with ADLs. Resident is able to make
simple needs known to staff. She is HOH and wears glasses for vision. Resident scored a 4 on BIMS. She
is able to repeat 3 words and recall 1 word with cues. Resident reports having some trouble sleeping and
has little interest in doing things. Resident is a Full Code. Resident is LTC.
During an interview with the DON on 02/16/2024 at 2:30 p.m., the DON confirmed the progress note, dated
5/27/2023, had been entered into Resident #5's clinical record in error. The DON further stated she
expected staff members to accurate record resident data to avoid confusion about residents' care or
condition.
2. Record review of Resident #73's face sheet, dated 02/15/2024, revealed the resident was admitted to the
facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Esotropia, and Personal History of
Covid-19. Further review revealed Bipolar Disorder was not a listed diagnosis.
Record review of Resident #73's Quarterly MDS assessment, dated 12/10/2023, revealed a BIMS score of
15 which indicated intact cognition.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 14 of 18
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
02/16/2024
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident #73's care plan, revised 03/10/2022, revealed, [Resident #73 has a behavior
problem r/t [related to] mood disorders and bipolar disorder.
Record review of Resident #73's clinical record revealed a physician note, dated 11/30/2023, which read,
Patient presents with bipolar disorder . Further review of Resident #73's clinical record revealed a physician
order, dated 11/2022, which read, QUEtiapine Fumarate Tablet 300 MG [milligrams]. Give 1 tablet by mouth
at bedtime for Bipolar.
During an interview with RN B on 02/14/2024 at 4:40 p.m., RN B confirmed Resident #73's diagnosis of
Bipolar Disorder was not listed on the resident's face sheet.
During an interview with the DON on 02/16/2024 at 2:30 p.m., the DON confirmed she expected staff
members to accurate record resident data to avoid confusion about residents' care or condition.
3. Record review of Resident #82's face sheet, dated 2/15/23, revealed the resident was admitted to the
facility on [DATE] with diagnoses including: [Candidiasis] a fungal infection caused by a yeast, [colostomy
status] an opening into the colon from the outside of the body which provides a new path for waste material
to leave the body after part of the colon has been removed, and [Bladder dysfunction] is the leaking of urine
that you can't control.
Record review of Resident's #82's Quarterly MDS addessment, dated 1/4/24, revealed a BIMS score of 15
which indicated intact cognition, and under under section H Bowel and Bladder section C selected
indicating colostomy status.
Record review of Physician Orders for February 2024 revealed an order for, Change colostomy bag every
three days and PRN (as needed).
Record review of Resident #82's (TAR) Treatment Administration Record for February 2024 revealed a staff
nurse was signing TAR and was not completing the treatment.
During an interview with Resident #82 on 2/15/24 at 1:35 p.m., the resdient stated he was educated on
colostomy care at [Name of Hospital] and completed his own colostomy care at the facility.
During an interview with RN C on 2/15/24 at 1:44 p.m., RN C stated she signs the TAR as per the facility
culture, and she had not been trained otherwise.
During an interview with the DON on 2/15/24 at 210 p.m., the DON stated she did not believe there were
any negative consequences for Resident #82 to be untrained by the facility. The DON stated she was
unaware nursing staff were signing the TAR and having the resident complete self colostomy care. The
DON stated it was her expectation that nursing staff compete the ordered task and then sign the TAR. The
DON stated the facility did not have a policy for this issue.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 15 of 18
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
02/16/2024
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 - Few
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based on record review and interviews, the facility failed to maintain spaces of at least 80 square feet per
resident for 14 of 15 Resident rooms (Resident rooms #101, 102, 103, 104, 105, 106, 107, 401, 403, 404,
405, 406, 408, and 409) 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,
408, and 409 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 02/13/24 which was filled out by the Administrator
indicated the capacity of the facility was 144 beds.
In an interview with the Administrator on 02/16/24 at 10:55 a.m., revealed she was not aware of any room
waivers for the facility.
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 - 76.35 square feet per bed
102 - 77.44 square feet per bed
103 - 76.49 square feet per bed
104 - 76.589 square feet per bed
105 - 76.124 square feet per bed
106 - 75.675 square feet per bed
107 - 76.83 square feet per bed
401 - 77.8145 square feet per bed
403 - 72.1485 square feet per bed
404 - 75.968 square feet per bed
405 - 75.40 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 16 of 18
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
02/16/2024
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
406 - 76.25 square feet per bed
Level of Harm - Minimal harm
or potential for actual harm
408-77.30 (allocated for 4 beds per the Form 3740)
409-78.19 (allocated for 4 beds per the Form 3740)
Residents Affected - Few
In an interview with the Administrator and Maintenance Director on 02/16/24 at 10:55 a.m. the
Administrator stated that the Bed Classification Form 3740 which she completed was accurate. The
Administrator stated she could not advise that a room waiver request had been submitted by the previous
Administrator. The Administrator stated she would like to apply for a room waiver request for the rooms
designated by the Life Safety Surveyor as not meeting room space capacity requirements.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 17 of 18
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
02/16/2024
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary,
and comfortable environment for residents, staff and the public, for 1 of 6 halls (400 hall) reviewed for
physical environment, in that:
The facility failed to secure loose flooring on the 400 hall.
This failure could place residents who reside in the facility at-risk of falls and further injuries due to an
unsafe environment.
The findings were:
Observation on 02/15/2024 at 08:35 a.m. revealed the flooring on the 400 hall was loose.
During an interview with the Maintenance Director on 2/16/2024 at 10:15 a.m., Maintenance Director
confirmed there was loose flooring on the 400 hall.
Record review of the facility's policy titled, Homelike Environment, revised February 2014, revealed,
Residents are provided with a safe, clean, comfortable, and homelike environment .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675469
If continuation sheet
Page 18 of 18
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
18 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F680 - The activities program must be directed by a qualified professional
Ensure the activities program is directed by a qualified professional.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the February 16, 2024 survey of HARMONY CARE AT FLORESVILLE?
This was a inspection survey of HARMONY CARE AT FLORESVILLE on February 16, 2024. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HARMONY CARE AT FLORESVILLE on February 16, 2024?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide properly protected cooking facilities."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.