Health inspection·October 25, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few activities, psych services as needed, and redirect during episodes of inappropriate sexual behavior and document in the clinical record. Record review of Resident #1's incident report authored by LVN A indicated on 06/15/2024 at 1:55 p.m. Resident #1 was observed by Resident #3 performing oral sex to Resident #2 in the dining room. Record review of Resident #1's progress note authored by LVN B indicated on 06/15/2024 at 2:03 p.m., [Resident #1] was separated from [Resident #2] area and placed [Resident #1] on the secure unit for now for safety and continue the 1-hour monitoring. Notified Abuse Administrator and DON of full incident. Record review of Resident #1's progress note authored by LVN A indicated on 06/15/2024 at 2:25 p.m., [Resident #3] was sitting in the dining room in the back and observed Resident #1 performing oral sex on Resident #2. CNA assisted [Resident #1] back to his room. [Resident #1] was unable to tell what happened due to Dx of moderate intellectual disability. [Resident #1] assess for any injuries, none noted. [Resident #1] started grabbing at his crotch area, no bruising or abnormalities noted from this area. Administrator, DON, ADON, MD notified, resident RP telephoned, no answer at this time, will continue to call. Resident placed on every 1-hour monitoring; vital signs B/P 122/67, pulse 74, respiratory rate 18, temperature 97.2. No c/o pain or discomfort observed. Record review of Resident #1's progress note authored by LVN A indicated on 06/15/2024 at 8:00 p.m., [Resident #1] was resting in bed at this time with eyes closed, no s/s of distress. No c/o pain or discomfort voiced. Resident RP telephoned x 4 attempts, wireless caller is unavailable at this time, will not allow to leave voice message. Record Review of Resident #1's behavior monitoring log indicated he was monitored hourly from 06/15/2024 at 2:00 p.m. to 07/22/2024 at 5:00 a.m. 2. Record review of a face sheet dated 10/24/2024 indicated Resident #2 was [AGE] years old male, initially admitted to facility on 06/17/2022 and readmitted to facility on 05/06/2024. His diagnoses included hemiplegia and hemiparesis following a cerebrovascular disease affecting left non-dominant side (a stroke or other cerebrovascular disease has damaged the right side of the brain, resulting in weakness or paralysis on the left side of the body), morbid (severe) obesity due to excess calories, post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar), depression (mental illness that negatively affects how you feel, the way you think and how you act) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. He had a BIMS score of 10 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. He required maximum assistance for most ADLS, requiring supervision for eating and oral hygiene. He was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #2's care plan with a revision dated 06/17/2024 indicated Resident #2 had inappropriate sexual behaviors and was at risk for further episodes and injury AEB, he allowed an intellectual challenged resident to perform oral sex on him in the dining room and stated the resident was an able body. Interventions included discharge planning (resident on parole), to firmly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 2 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few approach resident that behaviors were not acceptable, administer medications as ordered, inform direct caregivers on methods to assist them in handling resident's inappropriate sexual behaviors while providing care, provide diversional activities, psych services as needed, and redirect during episodes of inappropriate sexual behavior and document in the clinical record. Record review of Resident #2's incident report authored by LVN A indicated on 06/15/2024 at 1:55 p.m. Resident #3 observed Resident #1 performing oral sex to Resident #2 in the dining room. Incident description: Resident #2 stated I did not tell him to do it he just rolled up to me in his wheelchair and started performing sex on me. Resident #2 stated to CN and ADON, that Resident #1 (Dx: moderate intellectual disability) was an able body to suck my D***(penis). Resident #2 stated that he was going to call the police after this CN questioned him about the incident. Resident #2 was asked by the ADON why he did not back up and separate himself from the other resident because he had a power wheelchair, and he could remove himself from the situation. Resident #2 stated that the other resident was an able body. Record review of Resident #2's progress note authored by LVN A indicated on 06/15/2024 at 1:55 p.m., [Resident #3] reported that while she was sitting in the dining room in the back, she observed [Resident #1] performing oral sex on [Resident #2]. [Resident #2] stated that [Resident #1] asked the resident if it was good to him. CN interviewed the resident. [Resident #2] stated I did not tell him to do it he just rolled up to me in his w/c and started performing sex on me. [Resident #2] stated to CN and ADON, that [Resident #1] was an able body to suck my d***(penis), [Resident #2] stated that he was going to call the police after this CN questioned him about the incident. The administrator, DON, ADON, MD and local police were notified of the incident. Local police officer here, statement taken from [Resident #3] and [Resident #2]. Police Officer exit the building, case number given to ADON and administrator. RP notified (resident RP stated that she is not the resident RP the state of Texas is due to the resident being on parole). [Resident #2] remains up in motorized w/c going in and out of other resident's room. [Resident #2] was asked to go to his room, resident attempted to argue with staff. [Resident #2] stated f*** all of you, you have to do a lot of paperwork to get me out of here. You guys allowed this shit to happen. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 2:03 p.m., This ADON was called to facility to help with incident between two residents, when entering the facility and reporting to Nurses station, seen local Police Department officer there and getting statements from residents. [Resident #3] and [Resident #2] were in electric wheelchairs sitting there listening to conversations going on, I then asked both residents if I could speak to staff and officer to find out information of incident. [Resident #3] stated ok and moved away as asked, [Resident #2] remained for a while, and stated he would find out what was happening, then asked staff to take Resident #1 to separate him from area and place him on unit for now for safety and continue the 1-hour monitoring. Notified Abuse Administrator and DON of full incident. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 2:30 p.m., This nurse continued conversation with local police officer and was told that he will have to contact Special Victims and put this incident in their hands and someone would contact us to investigate further, he gave a paper with names of residents with case number of #2024-011832. He believed [Resident #2] was the one who initiated the incident but could not arrest him because of [Resident #1] had a Dx of Intellectual disabilities and he was unable to give a detailed description of incident, so it was being transferred to the proper unit and detective. [Resident#2] continues to come up to nurse station to listen what is being said and arguing with staff, after police left, I asked Resident #2 to go to his room so I could speak with staff, He then stated, call police or whatever, ya'll (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 3 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0600 allowed this shit to happen. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 3:20 p.m., I spoke with Medical Director related to incident and he felt the fact Resident #2 was on parole and posed a threat to other residents that we needed to discharge resident immediately, The police officer stated he could not just take him without proper investigation and charges, also if needed we could also send out Resident #1 if needed if resident started to get upset or seemed to be traumatized Residents Affected - Few from the incident. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 3:38 p.m., Resident #2 is aware we, both MD and facility are discussing immediate discharge and speaking to family on phone after police interviews and statements given. Resident #2 stating I won't be going anywhere soon to someone on the phone, and they have no idea how much paperwork they will have to do, in front of staff and residents, resident continues to cuss and become belligerent with staff. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 4:25 p.m., This nurse continues to move forward after family of Resident #2 stated they are not his RP and not responsible for him in any way, he is responsibility of the state of Texas, attempted to contact parole board as advised by family, Contacted local police department, that gave me a number to [local] Parole Board and spoke with representative who looked up residents name and stated she would have Resident #2's assigned parole officer to call back. Record review of Resident #2's progress note authored by LVN B indicated on 06/15/2024 at 4:30 p.m., This nurse received call back from assigned parole officer, who was trying to find out information to move forward with discharge and awaiting decision and investigation from local police department, he then asked for case number and stated he would see what he could do as soon as able. Record review of Resident #2's psychiatric evaluation authored by NP AA indicated on 06/25/2024, assessment details, Resident #2 was asked about incident that occurred on 06/15/2024 in dining hall with other resident, as per patients own words I was sitting in the dining room waiting for coffee and (Resident #1) came on my left side which is my blind side, he pulled up front of me, pulls my pants down and put his face in my crotch, he started giving me oral. I pushed him off and was looking to my right for nursing staff, I turned around and he jumped back on it. Treatment plan: utilize behavioral interventions to manage episodical behaviors, redirect as needed and provide support and encouragement to increase positive interactions and socialization, and follow up in 4 weeks or as needed. Record Review of Resident #2's behavior monitoring log indicated he was monitored hourly from 06/15/2024 at 2:00 p.m. to 07/23/2024 at 5:00 a.m. Record review of Provider Investigation report dated 06/15/2024 indicated Description of allegation: Resident #3 observed non-verbal Resident #1, alert x 1, performing oral sex to Resident #2, alert x 4, in the dining room. Assessments: Resident #1 was assessed for injuries with none noted. Provider Response: Resident #1 was immediately move to his room, assessed for injuries, none noted, Administrator, DON, ADON, Physician, and Responsible Party called. Resident #1 placed on Q 1 hour monitoring. After several attempts to get Resident #2 from the area to prevent further abuse, he complied and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 4 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few asked to go lay in his bed. Investigation Summary: Resident #2 was observed pulling Resident #1 head to his genitals and Resident #1 performed oral sex in the dining room. Resident #3, that observed the incident, reported it to the nurses. Resident #2 alert x 4 ambulates in a motorized wheelchair stated to the nurse He was an able body to suck by d k(penis) I did not tell him to do it, he just rolled up to me in his wheelchair and started performing sex on me. Resident #1 is alert x 1 ambulates in wheelchair and is nonverbal with intellectual disabilities. Parties notified: Physician, Administrator, Responsible Parties, DON, ombudsman, and ADON. Facility investigation finding confirmed. Provider action taken post-investigation: Local Police Department was called by Resident #2, referred ADON to contact special victims. Resident #2 is on parole, was issued an Immediate discharge, [NAME] Parole Board staff is assisting with discharges. Resident #2 was seen by LCSW with Psychological Services on 6-16-24. Resident #2 was monitoring every hour until discharged from facility. Resident #1 placed on every 1-hour monitoring, notified local LIDDA. Resident #1 with no behaviors noted, continue to call Responsible Party call goes to voicemail. During an observation and attempted interview on 10/24/2024 at 9:40 a.m., Resident #1 was sitting in his wheelchair in the hallway of the secure unit. He was appropriately dressed and well-groomed. He was unable to answer questions about the incident and just continued to reach out to touch or shake hands or hand/give a teddy bear. Resident #1 non-verbal. No indicators of abuse, neglect or distress observed. During an observation and interview on 10/24/2024 at 10:00 a.m., Resident #2 was lying in his bed in his room. He was lying in bed with no shirt on and well-groomed. He said that he gets warm easily, so he did not wear a shirt while in his room. Resident #2 was asked about incident that occurred on 06/15/2024 in dining hall with the other resident, as per patients own words I was sitting in the dining room waiting for coffee and (Resident #1) came on my left side, which is my blind side, he pulled up front of me, pulls my pants down and pulls out by penis and started giving me oral sex. I pushed him off and was looking to my right for nursing staff, I turned around and he jumped back on it. He said it lasted maybe 40 seconds, and I moved away as soon as I could. I didn't make him do that, called the police because he wanted it to be on record. Resident #2 said police officer visited with him and took his statement and report filed. Attempted to contact Resident #1's RP on 10/24/2024 at 5:30 p.m. and 10/25/2024 at 11:00 a.m. with no answer and unable to leave voice mail. During an interview on 10/23/2024 at 4:00 p.m., LVN A said that Resident #3 had reported to her that she observed Resident #1 giving oral sex to Resident #2 in the facility dining room. LVN A said that she went to the dining area but did not observe the sexual act. LVN A said she had CNA take Resident #1 to his room and she went to his room and did a head-to-toe assessment with no injuries noted. LVN A said she notified the MD, ADON, and the administrator and attempted to notify the RP but did not contact her. LVN A said that Resident #1 was placed on every hour monitoring and did not exhibit any s/s of distress from the incident during her shift. LVN A said that Resident #1 was placed in the secure unit briefly after the incident for his safety because Resident #2 was up in his electric wheelchair and refusing to go to his room and lie down, so placed Resident #1 in the secure unit until Resident #2 was placed in bed in his room. Attempted to call LVN B on 10/24/2024 @ 5:10 p.m. and 6:10 p.m. via telephone for interview, unsuccessful with no answer or returned call. Record review of facility census indicated that Resident #3, no longer resided at facility. An (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 5 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few attempt was made to call Resident #3 via telephone on 10/24/2024 at 5:15 p.m. and 6:15 p.m The attempts were unsuccessful with no answered or returned phone calls. During an interview on 10/24/2024 at 3:50 p.m., SW said that she was new to the facility but was aware of the incident between Resident #1 and Resident #2. She said that she had reviewed Resident #2's file and ongoing communications with probation officer and continues to work with other facilities for possible transfer or discharge of Resident #2 to another facility. SW said that Resident #1 and Resident #2 were provided behavioral support after the incident. During an interview on 10/24/2024 at 4:00 p.m., the ADON said she was not the acting ADON during the time of the incident between Resident #1 and Resident #2. She said she was aware that would be considered sexual abuse. The ADON said she notifies the Administrator/Abuse Prevention Coordinator immediately by phone/text of any allegation of abuse. The ADON said new protocol for abuse incidents was that staff should immediately remove residents from the situation and stay with the aggressor one-on-one until further instruction from the Abuse Coordinator or MD. ADON said Resident #1 resides in the secure unit and has no contact or communication with Resident #2. During an interview on 10/24/2024 at 4:55 p.m., the Administrator said she was not the active administrator during the incident between Resident #1 and Resident #2, but she had recently (10/05/2024 and 10/06/2024) conducted in-services with all staff addressing the facility abuse/neglect policy and initiating one-on-one monitoring with the aggressor until they were given further instructions on monitoring. She had addressed the different types of abuse and staff had passed a written test. She said she instructed staff on the documentation in behavior monitoring logs. She in-serviced staff on the facility's behavioral management policy which included resident abuse. She said staff were required to pass behavioral management test. She said not keeping the residents free from abuse could place them at risk of abuse, physical harm, mental anguish, and emotional distress. Record review of the undated facility's Abuse and Neglect policy indicated .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. III. Prevention: Have procedures to provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of retribution; and provide feedback regarding the concerns that have been expressed. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur. Establish a safe environment that supports consensual sexual relationship. Develop and implement policy on abuse, neglect, theft, exploitation, and misappropriation of property. Deployment of sufficient and trained staff to deal with behaviors in the units. Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect. The supervisions of staff to identify inappropriate behaviors .ensuring health and safety of residents .VI. Protect residents from physical and psychosocial harm during investigations. 1. If the allegation of abuse involves 2 or more residents, they will all be immediately separated for the protection of all residents involved and those potentially affected by the abuse. 2. Affected residents will be assessed for injury. 3. Attending physician will be notified. a. This includes but not limited to full assessment of physical and psychosocial well-being; sending resident to hospital if needed; depending on circumstance, keep resident on 1:1, assign a female/male depending on the accusation/allegation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 6 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of facility incident/accident reports indicated no other incidents of inappropriate sexual behaviors. Record review of quiz results, dated 10/05/24 and 10/06/24, indicated all staff passed the quiz regarding abuse, neglect, reporting, behavioral monitoring and one-on-one monitoring. Record review of a list of all facility staff used for tracking the required in-service training on abuse/neglect, behavioral monitoring, and behavioral management indicated all facility staff had received the in-service training in person or by phone on 10/05/2024 or 10/06/2024. During interviews on 10/24/24 from 3:30 p.m. though 5:30 p.m. and 10/25/2024 from 8:00 a.m. though 10:30 a.m., 4 LVNs (LVN A, LVN C, LVN D, LVN E ), 2 MAs ( MA P and MA Q), 10 CNA's (CNA F, CNA G, CNA H, CNA I, CNA J, and CNA K), 1 Activity Director, 1 Social Worker, 1 Dietary staff (Dietary Manager S), 3 Housekeeping staff (Housekeeper T, U, V) and 1 Maintenance (Maintenance W) were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the Administrator and were able to give examples of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified, such as immediately removing residents from the situation and stay with the aggressor one-on-one until further instruction from the Abuse Coordinator. They verbalized proper documentation of behavior monitoring logs. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 06/15/2024 and ended on 10/07/2024. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 7 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the State Survey Agency, for 4 of 15 residents (Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for reporting allegations of abuse. 1. The facility failed to report an allegation of abuse to the State Agency within 2 hours when it was reported on 01/25/2024 that Resident #4 cursed at and hit Resident #5. 2. The facility failed to report an allegation of abuse to the State Agency within 2 hours when it was reported on 08/27/2024 that Resident #6 hit Resident #7. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of a face sheet dated 01/23/2024 indicated Resident #4 was [AGE] years old male,, initially admitted to facility on 09/15/2023. His diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia affecting left nondominant side (damage to right side of brain from injury/stroke causing weakness or paralysis on the left side of the body), cognitive functions following cerebral infarction (difficulty with a person's ability to think, learn, remember, or make decisions after a stroke), anxiety (persistent and excessive worry that interferes with daily activities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #4 was able to make himself understood and understands others. He had a BIMS score of 08 (moderately impaired cognitively). He exhibited verbal behavioral symptoms directed towards others 1 to 3 days over the 7 days look back period. He required supervision for upper body dressing, and bed mobility, set up and clean up for eating and oral care and moderate assistance for other ADLS. He was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #4's care plan with a revision dated 01/25/2024 indicated Resident #4 had behavior problems- 1/25/24- verbal outburst- yelling at another resident and staff. Interventions included to receive orders for UA with C&S as indicated; referral to behavior facility; separated from other resident; abuse coordinator, regional clinician, MD, and Psych services all notified; every 1 hour checks/monitor whereabouts x 72 hours; administer medications as ordered, monitor/document for side effects and effectiveness; anticipate and meet the resident's needs; caregivers to provided opportunity for positive interaction, attention, stop and talk with him/her as passing by; if reasonable, discuss the residents behavior, explain/ reinforce why behavior is inappropriate and/or unacceptable to the resident; intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause, consider location, time of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 8 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0609 day, persons involved, and situations, and document behavior and potential causes. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #4's incident report authored by LVN X indicated on 01/25/2024 at 5:56 a.m., Incident Description: [Resident #4] approached Resident #5 in doorway inside bedroom and begin cursing at Resident #5, upon leaving nursing station Resident #4 struck Resident #5 inside of right thigh. Writer went to separate the two residents and Resident #4 proceeded to kick Resident #5 on the left foot. Resident was asked why he was being aggressive toward Resident #5 and he stated, 'Get that bumpy face bitch out my room' . Resident were separated from one another. Resident #4 redirected on refraining from hitting others. Notified physician of incident. Injuries observed at the time of Incident: No injuries observed at the time of incident. Mental Status: Oriented to person, oriented to situation and oriented to place. Agencies/People Notified: Physician and Nursing supervisor. Residents Affected - Some Record review of Resident #4's progress note authored by LVN X indicated on 01/25/2024 at 6:12 a.m., Resident #4 approached Resident #5 in doorway inside bedroom and begin cursing at Resident #5, upon leaving nursing station Resident #4 struck Resident #5 inside of right thigh. Writer went to separate the two residents and Resident #4 proceeded to kick Resident #5 on the left foot. Resident was asked why he was being aggressive toward Resident #5 and he stated, Get that bumpy face bitch out my room. Resident were separated from one another. Resident #4 redirected on refraining from hitting others. Notified physician of incident. Record review of Resident #4's progress note authored by LVN X on 01/25/2024 at 12:15 p.m., indicated Resident #4 had been admitted to Behavioral Center for his behavior. Resident left the facility with behavioral center staff x1. During an interview on 10/23/2024 at 3:00 p.m., Resident #4 said he did not recall the incident with Resident #5 from back in January 2024 and he knows that he is not supposed to hit or bite and/or curse other residents. Resident denies any abuse or neglect and is pleased with the care provided by the facility staff. Resident #4 said that he recalls being transferred to a behavioral hospital at the beginning of this year and they helped manage his medications. Resident #4 said that he was seen by psych services through the facility as needed and has gone to outpatient behavioral health services in the past. Record review of a face sheet dated 01/23/2024 indicated Resident #5 was [AGE] years old male, initially admitted to facility on 10/03/2016 and readmitted on [DATE]. His diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), dysphagia following stroke (difficulty swallowing after stroke), contracture (permanent tightening of the muscle, tendons, skin and nearby tissue that causes the joints to shorten and become stiff) to right shoulder and right elbow bullous disorder (skin condition that can cause blisters to form on the skin). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #5 was able to make himself understood and understood others. He had a BIMS score of 10 (moderately impaired cognitively). He exhibited no behaviors over the 7 days look back period. He required supervision for eating and maximum assistance for other ADLS. He was frequently incontinent of bladder and bowel. Record review of Resident #5's care plan with revision dated 01/25/2024 indicated Resident #5 had mood problems. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness; assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these; and Behavioral health consults as needed (psycho-geriatric team, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 9 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0609 psychiatrist etc.). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #5's incident report authored by LVN X indicated on 01/25/2024 at 5:58 a.m., Incident Description: Resident #5 was in wheelchair headed out into hallway when Resident #4 began cursing at him, the proceeded to swing at Resident #5 striking him on the right thigh. Writer stepped in and separated the two residents when Resident #4 proceeded to kick Resident #5 on left foot area. There was no bruising noted during time of incident and Resident #5 denied pain. Both residents were separated and educated on refraining from physical touch during conflict resolution. Resident #5 said he always cursing at me trying to hit me. Injuries observed at the time of Incident: No injuries observed at the time of incident. Mental Status: Oriented to person, oriented to situation and oriented to place. Agencies/People Notified: Physician and Nursing supervisor. Residents Affected - Some Record review of Resident #5's progress note authored by LVN X indicated on 01/25/2024 at 6:12 a.m., Resident #4 approached Resident #5 in wheelchair headed out into hallway when Resident #4 begin cursing at him, then proceeded to swing at resident striking him on his right thigh. Writer stepped in and separated the two residents when Resident #4 proceeded to kick Resident #5 on left foot area. There was no bruising noted during time of incident, denies pain. Residents were separated and educated on refraining from physical touch during conflict resolution. Physician notified, orders to monitor. During an interview on 10/23/2024 at 3:30 p.m., Resident #5 said he did not recall the incident with Resident #4 from back in January 2024 and denied hitting other residents or being hit by other residents. Resident #5 said that if another resident hits him he would notify the CNA or CN. Resident #5 denies any abuse or neglect and is pleased with the care provided by the facility staff. Attempted to call LVN X on 10/23/2024 @ 4:50 p.m. and 5:50 p.m. via telephone for interview, unsuccessful with no answer or returned call. During an interview on 10/24/2024 at 4:00 p.m., ADON 1 said Resident #4 had a history of behaviors including hitting and biting other residents. ADON 1 said when the behaviors/ incidents occurred that the residents are separated, and AC, RP, and physicians notified. ADON 1 said one on one monitoring was initiated with the aggressor until transferred to the behavioral hospital, or until further instruction from the Abuse Coordinator or MD. 2. Record review of a face sheet dated 09/01/2024 indicated Resident #6 was [AGE] years old male, initially admitted to facility on 03/28/2023 and readmitted on [DATE]. His diagnoses included seizures (a sudden, uncontrolled burst of electrical activity in the brain), altered mental status, schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder) dementia (loss of cognitive functioning), cognitive communication deficit (communication impairment caused by a cognitive deficit, rather than a language or speech deficit) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #6 usually understood others and was rarely/never able to make himself understood. He had a BIMS score of 02 (severely impaired cognitively). He exhibited inattention and disorganized thinking and exhibited behaviors not directed towards others 1 to 3 days over the 7 days look back period. He required supervision for bed mobility and eating and required maximum to moderate assistance for other ADLS. He was always incontinent of bladder and frequently incontinent of bowel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 10 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #6's care plan with revision dated 07/23/2023 indicated Resident #6 had the potential to be physically aggressive r/t Dementia. Interventions included to administer medications as ordered, monitor/document for side effects, and effectiveness; assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc; give the resident as many choices as possible about care and activities; and monitor/document/ report PRN any signs and symptoms of resident posing danger to self and others. Record review of Resident #6's incident report authored by LVN Y indicated on 08/27/2024 at 7:18 a.m., Incident Description: [Resident #6] stated that other resident (#7) hit his feet with his wheelchair, so he was angry and hit him. Immediate Action taken: Both residents were immediately separated and assessed for injuries. NP and RP notified regarding incident. Vital signs taken and monitored for increased behaviors. Injuries observed at time of incident: No injuries observed at time of injury. Mental Status: Oriented to person. Other information: Resident #6 has mental illness and dementia, he was impulsive. Agencies/People Notified: Physician and Nursing supervisor. Record review of Resident #6's progress note authored by LVN Y indicated on 08/27/2024 at 7:09 a.m., [Resident #6] hit [Resident #7] several times. ADON notified. Residents separated. 08/27/2024 at 10:13 a.m. [Resident #6] kicking, punching, spitting on staff. 08/27/2024 at 12:59 p.m. [Resident #6] continued to ride his wheelchair into anyone or other wheelchairs, he becomes aggressive when redirected or separated during his monitoring. Ativan administered per orders. Record review of Resident #6's progress note authored by Corporate RN Regional Director on 08/28/2024 at 8:30 a.m., indicated she was notified by Charge nurse that there was a resident-to-resident altercation. Another resident accidentally pushed his wheelchair and hit this resident's feet. In return this resident impulsively reacted and hit the resident. Both residents were immediately separated per nurse and continue monitor checks. All parties notified and physician, referral sent for inpatient psych for medication and behavior management. Record review of Resident #6's progress note authored by MDS Nurse Z on 08/28/2024 at 2:36 p.m., indicated call placed to behavioral hospital regarding possible referral due to residents increased agitation and combative behavior. Sent appropriate paperwork for possible admission. Received call from behavioral hospital with acceptance for resident for assessment and treatment for combative behaviors. Estimated time of arrive for Resident #6's pick up is 5:30 p.m. this evening per behavioral hospital van. Nurses station made aware of impending transfer. On 08/28/2024 at 2:40 p.m. Resident #6 is his own responsible party. Consent signed by 2 nurses and resident made aware of situation and impending transfer. Record review of Resident #6's progress note authored by LVN A on 08/28/2024 at 6:20 p.m., indicated patient attendant here from behavioral hospital to transport Resident #6 to behavioral hospital. Resident #6 sitting up in wheelchair on the secure unit. Resident clean and dry. 2 CNAs and CN assisted in propelling the resident in the w/c to the front, resident spitting and swinging at the staff, resident needed assistance by staff to be placed on the w/c van. Resident repeatedly removed seat belt buckle on the van and attempted to spit at the staff and on the van driver. Resident combative and agitated, medicated with Ativan 1 ml IM, administered right deltoid, tolerated well. Resident alert/confused, no signs or symptoms of distress upon leaving facility. Resident left facility with clothing in red suitcase. Record review of Resident #6's progress note authored by Corporate RN Regional Director on 09/01/2024 at 11:24 p.m., Clarification, incident was on 8/27 not 8/28 and on 09/01/2024 at 11:27 p.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 11 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0609 Incorrect charting from nurse. Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 10/23/24 at 9:39 a.m., Resident #6 was sitting in his wheelchair in the dining room of the secure unit. He was appropriately dressed and well-groomed. He was unable to answer questions about the incident. Residents Affected - Some Record review of a face sheet dated 10/24/2024 indicated Resident #7 was [AGE] years old male, initially admitted to facility on 03/02/2023 and readmitted on [DATE]. His diagnoses included dementia (loss of cognitive functioning), memory deficit following nontraumatic intracerebral hemorrhage (memory loss or deficit following a type of stroke that occurs when a blood clot forms in the brain), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), hypertension (condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #7 was usually able to make himself understood and usually understood others. He had a BIMS score of 08 (moderately impaired cognitively). He exhibited physical behavioral symptoms towards others 1 to 3 days over the 7 days look back period. He required supervision for bed mobility and eating and moderate to maximum assistance for other ADLS. He was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #7's care plan with revision dated 05/04/2024 indicated Resident #7 had potential to be physically aggressive related to dementia, Poor impulse control. Interventions included to administer medications as ordered. Monitor/document for side effects and effectiveness; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc.; communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; modify environment: Adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room, keep door closed etc.); monitor and Document observed behavior and attempted interventions in behavior log; psychiatric/psychogeriatric consult as indicated; and when the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #7's progress note authored by LVN Y indicated on 08/27/2024 at 10:15 a.m., Resident #7 returned from physical therapy agitated and hitting staff. Raising fist at staff saying, I am going to punch you out NP notified. New order Ativan IM Q 12 hours for agitation. Record review of Resident #7's progress note authored by MDS Nurse Z on 08/28/2024 at 9:15 a.m., indicated Late entry for 8/27/2024 Call placed to Responsible Party to inform that resident has been having changes in behavior, both inappropriate sexual behavior and aggressive behaviors. Resident has been accepted at behavioral hospital. Responsible party states ok thank you for the call. Record review of Resident #7's progress note authored by Corporate RN Regional Director on 08/28/2024 at 9:34 a.m., indicated she was notified approx. 8 a.m. by charge nurse that there was a resident-to-resident altercation involving this resident. This resident was heading to the dining room and his wheelchair hit another resident's feet. The other resident hit this resident and were immediately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 12 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some separated by staff. This resident denied pain, charge nurse conducted a skin assessment, no injuries noted. All parties were notified. Record review of Resident #7's progress note authored by ADON 1 on 08/28/2024 at 10:32 a.m., indicated Resident left Facility via w/c X1 assist with transportation in route to behavioral hospital. Pt alert and oriented X2. Pt had no complaints at the time of transport. Will continue to f/u as changes occur. Pt's daughter notified that pt has left facility at this time. Record Review of Provider Investigation report on 08/27/2024 indicated that incident category was abuse, incident date was 08/27/2024 and the time of incident was 8:00 a.m. Description of allegation: Resident to resident altercation. Assessment date 08/27/2024 at 8:00 a.m. Head to toe assessment completed by LVN no injuries noted during assessment. Agency Immediate Response: immediately separated the two residents, assessed for injuries. Placed them in monitoring checks due to the physical aggression. Investigation Summary: Staff and residents were interviewed regarding incident. Per staff, Resident # 7 was wheeling in his wheelchair to the dining room in the secure unit, when he bumped into Resident #6 and hit his feet with his wheelchair. In return Resident #6 reaction was to slap Resident #7, before staff could get to both of them, physical contact had already occurred. They were both immediately separated and assessed for injuries and pain. No injuries were noted, both denied pain. Agency Action Post Investigation: Both Resident #6 and Resident #7 were both evaluated by in patient behavioral hospital for admission and were accepted, currently at behavioral hospital. Date reported to HHSC 08/27/2024 Time: 9:00 a.m. Record review in TULIP (an online system for submitting long-term care licensure applications and tracking complaint and SRI intakes) revealed a self-report was made regarding Resident #6 and Resident #7's incident by the Corporate RN Regional Director dated 08/28/2024 and received time of 9:38 a.m., greater than 24 hours after the incident occurred (08/27/2024 @ 7:18 a.m.). During an observation and interview on 10/22/2024 at 11:45 a.m., Resident #7 was sitting up in wheelchair in secure unit dining room. He said he did not recall the incident involving resident to resident altercation or him running over anyone's feet with his wheelchair. Resident #1 said that he knew that he was not supposed to touch or hit other residents or staff. During an interview on 10/24/2024 at 4:00 p.m., ADON 1 said Resident #6 and Resident #7 had a history of behaviors including hitting other residents and staff. ADON 1 said when behaviors/ incidents occurred that the residents were separated for safety, and AC notified immediately, and RP and physicians notified. ADON 1 said one on one monitoring was initiated with aggressor until transferred to behavioral hospital or until further instruction from the Abuse Coordinator or MD. ADON 1 said the abuse allegation had to be reported to the state agency within 2 hours, so all abuse allegations needed to be reported immediately to the AC. ADON 1 said failure to report abuse allegations could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. During an interview on 10/24/24 at 4:50 p.m., the Administrator said that she was not the active Administrator/Abuse Coordinator at the time of these abuse allegation incidents. She said her expectation for incidents involving resident to resident abuse was for the residents to be separated and the aggressor to be placed on one-on-one monitoring for the protection of other residents. She said she as the AC should be notified immediately so the investigation could begin and report the allegation to the state agency within 2 hours. She said the possible negative outcome of not reporting abuse allegations could put residents at risk for physical, emotional, or psychological harm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 13 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0609 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Abuse and Neglect policy dated June 2023 indicated . VII. Reporting/Response (483.13 (c)(1)(iii), 483.13 (c)(2) and 483.13 (c)(4)): Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee; All allegations of abuse will be reported to DADS immediately after the initial allegation is received. Residents Affected - Some REPORTING: All allegations and/or suspicions of abuse/neglect must be immediately reported to the facility Administrator or designee in the absence of the administrator. Failure of an employee to report an allegation and/or suspicion of abuse will result in disciplinary action. The Administrator is the Abuse Coordinator. Preliminary Investigation Report: The abuse coordinator must submit a preliminary investigation report to DADS immediately once assurances for the resident's or other resident's safety have been established. However, if the event that caused the allegation of abuse results in serious bodily harm, the allegation of abuse must be reported to DADS immediately and not later than 2 hours after receiving the allegation of abuse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 14 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 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 PASRR comprehensive service plan was implemented for 1 of 2 residents reviewed for PASRR assessments. (Closed Record #8) The facility did not provide and arrange for specialized physical therapy, occupational therapy, and speech therapy services for Closed Record #8 as recommended and agreed upon by the IDT within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services that would enhance their quality of life. Findings included: Record review of a face sheet dated 10/22/24 indicated Closed Record #8 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression and bipolar disorder), cerebral palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development, often before birth), dysphagia (difficulty swallowing), and aphasia (a language disorder that affects a person's ability to understand and express written and spoken language). Record review of a PASRR Comprehensive Service Plan (PCSP) dated 01/24/24 for Closed Record #8 indicated the IDT recommended and agreed on specialized occupational therapy, specialized physical therapy, and specialized speech therapy. Record review of a care plan last revised 04/17/24 indicated Closed Record #8 was PASRR positive for intellectual disability. Goals included for Closed Record #8 to understand and participate in the treatment plan. Record review of an MDS dated [DATE] indicated Closed Record #8 had severe cognitive impairment. He was considered by state level II PASRR process to have serious mental illness and intellectual disability. He had unclear speech and was usually understood and usually understood verbal communication. He required substantial or maximal assistance for most activities of daily living and used a wheelchair for mobility. During an interview on 10/22/24 at 10:30 a.m., the Director of Rehabilitation said she submitted the occupational therapy, physical therapy, and speech therapy evaluations for Closed Record #8 to the previous MDS Nurse, but they were never authorized. She said he did not begin receiving therapy services through PASRR until 4/17/24 which was well after the time frame requirement from the PCSP and IDT meeting completed on 01/24/24. During an interview on 10/23/24 at 4:05 p.m., the Regional Director of Reimbursement said PASRR requirements mandate that the facility complete an accurate request for NF specialized services recommended and agreed upon at the PCSP and IDT meeting into the online portal within 20 business days and therapy services started within 3 business days after receiving approval from HHSC in the online portal. She said CR #8 did not receive his therapy services through PASRR as agreed upon in the PCSP meeting completed on 01/24/24. She said Closed Record #8 was currently at a behavioral hospital and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 15 of 16 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 675595 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Beaumont 2660 Brickyard Rd Beaumont, TX 77703 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 0644 was expected to return to the facility. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/23/24 at 4:15 p.m., the Administrator said she was not working at the facility during the time of Closed Record #8's PCSP and IDT meeting on 01/24/24. She said possible negative outcome of not meeting the PASRR timeframes for beginning recommended services could be residents not receiving services as approved through PASRR. Residents Affected - Few Record review of an undated facility policy titled PASRR indicated . If the Level II evaluation confirms an intellectual disability, mental disorder, or developmental disability diagnosis the facility collaborates with local resources when special services are required. If special services are required, the facility the facility will coordinate services per state policy and develop a care plan that addresses the specific needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675595 If continuation sheet Page 16 of 16