Inspection·January 18, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm In an observation on 01/17/24 at 12:29 pm, Resident #2 was lying in bed. The enteral feeding pump machine had been turned off and the G-tube feeding bag and the hydration bag had been removed. In an observation on 01/17/24 at 1:15 pm, Resident #2 was still lying in bed. The enteral feeding pump machine was still turned off and no changes had been made since the resident was last observed. Residents Affected - Few In an interview on 01/17/24 at 1:32 pm with the ADON, he stated that G-tube orders vary by resident. To check the orders for Resident #2, the ADON went to the nurse's station to log into PCC. He read that Resident #2 was ordered to receive feedings for 22 hours per day, and the pump was to be turned off at 1600 (4pm) and turned back on 1800 (6pm). The ADON also stated that Resident #2 was NPO. As the ADON was being interviewed, LVN was also sitting at the nurse's station. LVN looked back and forth between the investigator and the ADON during their conversation. The investigator noticed this and asked the ADON to accompany them to the resident's room. In Resident #2's room, the enteral feeding pump was turned off and the hydration and feeding bags had been removed. When asked where the feeding bag was, he stated that he did not know and he would have to check with the nurse who worked there. The ADON stated that as long as the resident was on the machine for 22 hours a day it should be fine. When the investigator reiterated that the orders said to hold from 1600 to 1800, not 1200 to 1400, ADON responded yeaaaaa . and eased out of the room. In an observation on 01/17/24 at 1:35 pm, LVN was outside of Resident #2's room with the medication cart and has begun to grab bottles of Nutren 2.0 and feeding bag supplies. In an interview on 01/17/24 at 1:36 pm, LVN explained to me that she removed the feeding and hydration bag around 1pm because she noticed the bag was empty. The investigator explained that her time of events was incorrect and that the bags had first been observed removed at 12:29pm. The LVN explained that she was going to replace the bags, but she had not finished passing the 12pm medications. When asked what the orders were, she responded that she did not know but she did know that the bag is supposed to be turned off between 4pm (1600) and 6pm (1800) daily. When asked why she had unofficially changed the hold time for Resident #2 and she responded that I am doing it now. The investigator asked why did she not replace the bag when she saw it was empty/beeping with an error. She again responded I am doing it now. In an observation on 01/17/24 at 1:42 pm, LVN had begun to prepare the enteral feeding pump for administration. After she set everything up, LVN began to reattach the G-tube to the connecting piece on the resident's stomach and realized that it was clogged, and the enteral feeding pump read error. LVN told the investigator that she needed to find an unclogging device and she would finish setting up Resident #2's feeding equipment. Record review of Resident #2's active orders displayed that at 1347 (1:47 pm), DON added a new order that stated May have feeding off for 2 hours/day for ADL care, therapy, bed mobility, medication administration. The order was checked off that it was communicated verbally and was ordered by NP. Further review of the audit details behind this order displayed that this order had been signed off by the DON and the NP listed had not signed/confirmed the order for verification. In an interview on 01/17/24 at 1:57 pm, CNA A stated that he worked on the same hall as Resident #2, but he did not work with her that day, however, he worked with residents to the right and across the hall from Resident #2. He revealed that he heard Resident #2's enteral feeding pump consistently beeping around 9/9:30 am. He said that although he did not go into the room, he knew the beeping noise was from her machine because the resident that he worked with to the right of Resident #2 also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 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 had a feeding pump, but her machine was quiet and the bag was half full. CNA A also stated that he was sure of the time because that is when he did his rounds and completed the 2nd changing for residents on that hall. In an observation on 01/17/24 at 3:00 pm, Resident #2's initial order to turn off the pump at 1800 and turn on at 1600 for enteral feeding had been removed from view in PCC and a new enteral feeding order had been added. In an interview on 01/17/24 at 4:08 pm with NP, she stated that the orders for Resident #2 was for the pump to be turned off at 4pm (1600) and turned back on at 6pm (1800). She stated that she had not checked her phone or email so she did not know if she had received any requests to change Resident #2's order but the facility is allowed to turn the pump off if the resident is going to therapy. The investigator let NP know that the resident is a hospice patient and does not receive therapy services. She stated that she would have to check Resident #2's chart because she did not have the information in front of her. NP also stated that if the pump was off for 4-5 hours, or more than 2 hours, the facility would have to let her know because the resident could only be off the machine for 2 hours. In an observation on 01/17/24 at 4:30 pm, Resident #2 is lying in her bed and the enteral feeding pump had been turned back on. The error message had been resolved and there was no more beeping. Record review of Resident #2's active enteral feeding orders revealed that the order was signed by the NP on 01/18/24 before 10am (exact time undocumented). In an interview on 01/18/24 at 1:36 pm with CNA C, she explained that she worked with Resident #2 on 01/17/24. She said that she did rounds every 2 hours with residents. She stated that the enteral feeding pump was beeping at 10am but she did not look at the pump to see what it meant. She explained that when the pump is beeping, it meant that the machine is messed up or it needed more food, but she did not check. She stated that she did not tell the nurse that the machine was beeping at 10am but she did tell LVN at 12pm. When asked why she did she tell LVN at 10am when she initially heard it beeping, she gave a different response and said the machine beeped once at 10am and when I heard it beeping at 12pm, I told LVN, who turned the machine off. In an interview on 01/18/24 at 3:04 pm with DON, she stated that she changed the orders because if staff needed to do ADL care or something, there should not be a set time. She explained that LVN came in on 01/17/24 around 9am because the scheduled nurse for 6am had called in that morning. This gave her a late start for administering medications. When asked if she had the authority to change orders without confirmation from the NP, she stated that she could change the order and stated that enteral orders are batch orders and whatever you select is what is placed in the chart. She stated that the initial orders had been removed from the active order view in PCC because she had discontinued them. In an observation on 01/18/24 at 5:41 pm, Resident #2 was in bed and appeared comfortable. Her enteral feeding pump had been turned off. In an interview on 01/18/24 at 5:44pm, LVN stated that she turned the enteral feeding pump off at 4pm because she is following the order that said to turn the pump off at 4pm (1600). Record review of the facility's Nursing Policies and Procedures, subsection Medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 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 Administration and Management stated that the authorized licensed of certified/permitted medication aide or by state regulatory guidelines staff member identifies that the following information, but not limited to, is documented on the MAR: A. Residents Affected - Few Correct physicians orders B. Medication and label are correct C. Label and physicians orders are correct Record review of the facility's Nursing Policy and Procedure Manual, under the subsection of Care Plans (revised 10/2023) reflected that: A. A comprehensive, person-centered care plan is developed and implemented for each resident to meet the resident's physical, psychosocial, and functional needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as is possible for one (Resident #1) of six residents reviewed for transfers. CNA A failed to lock Resident #1's wheelchair during a transfer. This failure could place residents who require assistance during transfers at risk for falls and injuries. Findings include: Record review of Resident #1's face sheet revealed a sixty-nine-year-old male who was admitted to the facility on [DATE]. His admitting diagnoses Type 2 Diabetes (the body does not produce enough glucose to energize the cells), heart failure, unspecified dementia (memory loss), unsteadiness on feet, and abnormalities of gait and mobility. Record review of Resident#1's care plan revised 01/21/23 focus area revealed an ADL self-care performance deficit. Interventions detailed that Resident #1 was dependent on staff to move from sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and tub/shower transfer. Record review of Resident #1's most recent weigh in on 01/05/24 revealed that he weighed 224.8lbs standing. Record review of Resident #1's BIMS (a mandatory tool used to screen and identify the cognitive condition of residents) score reflected a score 09 (moderate cognitive impairment) out of 15. In an observation on 01/17/2024 at 1:00 pm, Resident #1 was being pushed in his wheelchair from the dining room by CNA A. Resident #1 had begun to slide down in the wheelchair, where his bottom partially hung out of the chair and his head was leaning against the back rest. CNA A asked the LVN if she could help him reposition the resident back into the chair. As the LVN walked over to Resident #1, CNA B walked up and said hey, I got it and proceeded to assist CNA A with the resident. CNA A stood on Resident #1's right side and leaned over to grab the resident under his right arm. CNA B grabbed the resident under his left arm. As both CNA's attempted to reposition the resident in his wheelchair, Resident #1's wheelchair rolled backwards and slammed into the door frame of another resident's room. CNA A and CNA B exclaimed in panic as the resident slid down further to the floor but were able to stop Resident #1 from hitting the floor. LVN stated the wheelchair! You have to lock the wheelchair! and walked behind the wheelchair to hold it in place and lock it. CNA A and CNA B managed to reposition Resident #1 properly into his wheelchair and CNA A rolled him back into his room. In an interview with CNA A on 01/17/24 at 1:57 pm, he stated that he noticed Resident #1 was sliding down in his wheelchair. He explained that his wheelchair locks from the back by stepping on a pedal but it is difficult to unlock. CNA A expressed that he forgot to lock the chair while they readjusted Resident #1. He also expressed that in the past, he had forgotten to lock the chair during a transfer/adjustment, but it is not all of the time. CNA A stated that the chair should always be locked during transfer to make sure the resident doesn't fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675700 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Brookshire 710 Hwy 359 S Brookshire, TX 77423 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 0689 Level of Harm - Minimal harm or potential for actual harm In an interview with Resident #1 on 01/17/24 at 2:10 pm he stated that CNA A is rough with him during transfers and that he slipped down in his chair today (01/17/24) and yesterday (01/16/24). During the interview, the investigator told Resident #1 that they witnessed the transfer in the hallway and he almost fell. Resident #1 looked into the investigator's eyes and began to cry. The investigator apologized for his discomfort and Resident #1 stated they always transfer me rough. Residents Affected - Few In an interview on with the DON on 01/18/24 at 3:04 pm, she stated that she had not given nor had the facility preformed any in-services on transfers within the last 90 days. When the DON was informed about what occurred between CNA A and Resident #1, she stated that it was common sense to lock the wheelchair. She stated Poor Resident #1, I know he was embarrassed. The wheelchair should always be locked before any transfer or even when the resident is sitting in place. This is important for us to know because although it is not intentional, it could be perceived as a form of abuse. In an interview with LVN on 01/18/24 at 4:02 pm, she explained that earlier that day with Resident #1, CNA A did not lock the wheelchair and she believed he forgot to do so. She explained that the chair should be locked every time you transfer someone. Anytime you transfer, you have to lock the wheelchair, even if it is in place. Record review of CNA A's Nurse Aide Skills Performance Checklist under lifting and transfer skills displayed that CNA had passed on a satisfactory level on 03/01/2023. Record review of the facility's policy on Safe Lifting and Movement of Residents (not dated) stated that: A. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. B. Safe lifting and movement of resident is part of an overall facility employee health and safety program, which: a. involves employees in identifying problem areas and implementing workplace safety and injury prevention strategies; b. addresses reports of workplace injuries c. provides training on safety, ergonomics, and proper use of equipment; and d. continually evaluates the effectiveness of workplace safety and injury-prevention strategies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675700 If continuation sheet Page 6 of 6