Health inspection·July 10, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public on three of five halls observed (hall 100, 400 & 500). Floors on Secured unit (hall 100) were dirty and stained. Resident bathrooms on halls 100 were unkept, unclean, had strong urine odor and unsanitary. Window blinds on halls 100, 500 were bent and torn and Hall 400 vertical blinds had missing slats. Windows on hall 100 has an accumulation of spider webs and green stuff on the outside. The toilet bowls on hall 100 had brown and black stains in them. The tiles in rooms on 100 hall was broken, based boards not affixed to the wall, broken sheet racks and peeling paint on the wall. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings included: Observation of Hall 100 on 07/10/2024 between 11:10-11:40 AM reveal the following: *room [ROOM NUMBER] had broken floor tiles at the entrance door, near the window tiles were lifting off the floor. Baseboard was not affixed to the wall and the sheet rack was torn. The bathroom had strong urine order. *room [ROOM NUMBER] baseboard was off the wall near the bathroom and broken window blinds. The toilet bowl had brown stains and strong urine odor. The shower stall (not in use) had what looked like a dirty towel on the floor and brown stains on the floor. *room [ROOM NUMBER] had broken window blinds and the baseboard was not affixed to the wall. *room [ROOM NUMBER] had broken sheet rack to the bathroom door, peeling paint on the bathroom door, broken window blinds and missing baseboard near the right of closet. (continued on next page) 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 4 Event ID: 675700 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 07/10/2024 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)