Health inspection·February 15, 2023

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to have a provide an activities program directed by a qualified professional for 1 of 1 activity directors ( AD) reviewed for qualifications. Residents Affected - Some The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. 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 included: Review of AD's employee file revealed the AD took the position on October 31, 2022, and no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements During an interview on 02/15/23 at 3:20 PM the AD stated she did not have her Activity Director certification and she would start training program March 7th, 2023. The AD stated she had no prior experience as an AD, had been working in the kitchen and assisted the prior AD. During an interview on 02/15/23 at 3:26 PM the ADMIN stated her expectation was to hire someone already certified as an Activity Director but could not find anyone who was already certified. The ADMIN stated the AD had not started her certification prior to hiring. The ADMIN stated she was responsible to monitor the AD's progress and completion of her certification. The ADMIN stated the facility's location was what led to failure of not hiring a certified Activity Director. The ADMIN stated she did now know of any affect to residents for AD not having her certification. Review of the facility's job description for Activity Director signed on October 31, 2022 revealed, EducationTo be qualified, must meet one of the following criteria: 10% completion of a state approved training course: Qualification as Occupation Therapist or Therapist Assistant and/or Qualification as an Activity Professional or Recreational Therapist who is: Licensee or registered either nationally or by the state in which practicing; and eligible for certification as a Activity Professional or as a Therapeutic Recreational Specialist by a recognized accrediting body on or after October 1st, 1990. Experience- Two years of experience conducting social/recreational programs within the past five years, one of which was full-time in a patient actives program in a health care setting. Page 1 of 9 675769 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, interviews, and record reviews, the facility failed to maintain an environment that was free from accident hazards for 1 of 1 storage rooms reviewed for accident hazards. Floor stripper, sanitizing/disinfectant, floor buffer, and paint was stored in a resident room that was open and accessible to all residents of the facility. This failure could place residents at risk of injury due to hazardous chemicals. Findings included: During an observation on 2/15/23 at 3:45 PM of resident room [ROOM NUMBER], the door was held in place, open, braced by a 3-drawer dresser. The room had the following chemicals: 1-1-gallon plastic jug half full of liquid floor stripper 4-1-gallon plastic jugs of Disinfectant + Sanitizer on top of 1 closed box of 4- 1-gallon plastic jugs of Disinfectant + Sanitizer. 1-open box containing 12 -32 oz bottles of Buffer spray. 1-can of QD electronic cleaner aerosol spray. 4-1-gallon buckets of Interior Semi-Gloss Acrylic paint. 3-5 gallon buckets Interior Semi-Gloss Acrylic paint. 1-paint drip pan that had thick white substance and a paint roller laying in it. 1-red plastic container 1/3 full of white substance with paint brush inside. During an interview with MM on 2/15/23 at 4:25PM, he said the white substance was paint he had been using earlier in the day while painting the hallway. He said the door was left open and unlocked because he did not have a key to lock the door. MM said the chemicals were stored in the room because it was an inside space that was close for the floor buffing equipment to be used in the facility. He said the chemicals should have been stored outside in their storage building away from resident access because any resident could pick them up and ingest them. MM said the closed fire doors for the hallway were unlocked nor was the dining room door locked and they did not prevent resident access from hallway 3. He said the chemicals should have been stored in a locked room. MM said if a resident wandered into the room and ingested any of the chemicals, they could become very sick. During an interview with ADM on 2/15/23 at 5:25PM, she said the chemicals should have been stored outside away from resident access. The double doors and the dining room door were not locked to prevent residents from access down hallway 3 of the building and they could potentially go in the room with the chemicals. 675769 Page 2 of 9 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0689 Level of Harm - Minimal harm or potential for actual harm Record review of MSDS for Floor Stripper revised 11/13/13 revealed: Harmful if swallowed. May cause irritation of the digestive tract. May cause gastrointestinal irritation with nausea, vomiting and diarrhea. Causes eye burns. Causes burns. Causes gastrointestinal tract burns. Causes severe pain, nausea, vomiting, diarrhea, and shock. May cause corrosion and permanent tissue destruction of the esophagus and digestive tract . may cause respiratory tract irritation. Causes skin irritation. Residents Affected - Some Record Review of MSDS for Disinfectant + Sanitizer revised 7/9/20 revealed: hazards for health of people, results of possible effects: can irritate eyes. In case of eye contact, eyes can get red, they can [NAME]. In case of skin contact the affected skin can become sensitive or injured irritation, skin can become red. It can cause slight health disorders when inhaled or ingested. Record Review of MSDS for Floor Buffer revised 11/13/13 revealed: may be harmful if swallowed. May cause gastrointestinal irritation with nausea, vomiting and diarrhea. May cause kidney damage. May cause central nervous system depression. May be harmful if inhaled. Causes respiratory tract irritation. High vapor concentrations may cause drowsiness . May cause kidney damage . May be harmful if absorbed through the skin. May cause mild skin irritation. Continued absorption may cause kidney damage. Prolonged or widespread skin contact may result in the material being absorbed in harmful amounts. Causes eye irritation. Record Review for [NAME] Ultra Spec 500 Semi-Gloss Acrylic Paint revealed: Keep Out Of Reach Of Children . use only with adequate ventilation. Do not breathe spray mist or sanding dust. Ensure fresh air entry during application and drying. Avoid contact with eyes and prolonged or repeated contact with skin. Avoid exposure to dust and spray mist by wearing a NIOSH approved respirator during application, sanding and cleanup . Close container when not in use. This product can expose you to chemicals including titanium dioxide, which are known to the state of California to cause cancer, and Toluene which are known to the state of California to cause birth defects or other reproductive harm. Record Review oof Facility Policy labeled Location of Hazardous Chemicals revised 02/2013 revealed: Locations where hazardous chemicals and/or materials are used, stored, or transported are identified and marked. Hazardous chemicals and/or materials are maintained in the following locations: There was no area identified in policy for storage of hazardous chemicals and/or materials. 675769 Page 3 of 9 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week, days reviewed for between 02/13/2022 to 08/28/2022. Residents Affected - Some The facility failed to provide RN coverage for a minimum of 8 hrs a day in a 24 hr work period 7 days a week. This failure could place residents at risk of improper and/or inconsistent nursing care services and clinical needs not being met. Findings include: Record review of RN timesheets 01/2022 to 12/2022 revealed 5 days of no RN or less than 8 hours of RN coverage, which were as follows: *02/13/2022 with 0 RN coverage *05/07/2022 with 0RN coverage *05/08/2022 with 0RN coverage *06/12/2022 with 0RN coverage, and *08/28/2022 with 0RN coverage In an interview on 02/15/23 at 05:32 PM, the DON stated she was aware there was one day there were not the appropriate number of RN's staffed and unaware of the other missed days. She said the negative impact to residents would be, untimely care with not having RN supervision, she as DON, stated she should have been monitoring her staffing more to make sure they had the proper staff coverage. The failure was her staff not communicating with each other, not notifying her if there were call in's for days missed. Her expectations were for staff to let her know early enough so she could have found coverage and staff. In an Interview on 02/15/23 at 5:59 PM, the ADMIN stated, she did not have evidence of all RN coverage and was not aware of the shortage of coverage. The negative impact to residents would be quality of care for the residents and stated there were LVN's that were staffed. The only thing she stated she could think of for the failure that occurred, was for RN's to become hourly pay so they can clock in and/or out for a paper trail. Her expectations for RN coverage were to have no less than 8 hr.'s a day 7 days a week with the DON monitoring. Record Review of the facility's Facility Operational Policy and Procedure Manual for Long Term Care dated 1st period-2020 did not address the use of services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week. No other policies were provided before exit of this facility. 675769 Page 4 of 9 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility's kitchen staff failed to practice proper hand hygiene during meal preparations. The facility's kitchen staff failed to ensure foods were sealed and/or labeled properly in dry food storage, refrigerators and freezers. The facility failed to ensure that all persons in kitchen wore appropriate hair coverings. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: During observation on 02/13/2023 between 10:50 and 11:20 PM in the kitchen revealed: Dry Storage #1 1. A plastic container that contained oatmeal cream pies not labeled with a receive or use by date. 2. A plastic container that contained fudge rounds not labeled with a receive or use by date. 3. A plastic container that contained cheese crackers not labeled with a receive or use by date. 4. A plastic container that contained peanut butter crackers not labeled with a receive or use by date. 5. A 6 lb. diced tomatoes can was dented. 6. A plastic container that contained brown sugar that was not sealed with a white powdery substance and an onion peel in container. 7. 675769 Page 5 of 9 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0812 Two plastic containers that contained elbow pasta that were not sealed. Level of Harm - Minimal harm or potential for actual harm Dry Storage #2 1. Residents Affected - Many Three 46 Fl OZ boxes of thickened sweetened tea with a use by date of January 19, 2022. 2. Four 46 Fl OZ boxes of thickened water with a use by date of January 1, 2022. Freezer #1 1. A tub of ice cream that was not sealed and was open to air. During an observation on 02/13/2023 between 11:50 and 12:35 PM in the kitchen revealed, DS C was serving lunch trays and was not wearing gloves. DS C removed toast from toaster with an ungloved hand, then touched her nose without performing proper hand hygiene. DS C continued to serve lunch tray without performing hand hygiene and touched her face several times without stopping to perform hand hygiene. During an observation on 02/14/2023 at 10:40 AM in the kitchen revealed the ADMIN, MM A, and MM B entered the kitchen and did not perform hand hygiene or wear a hair covering. The ADMIN, MM A and MM B walked across kitchen to look at cabinets, standing over area that was set up to start puree for lunch service. During an interview on 02/13/2023 at 11:20 AM the DM stated food items should have either a receive date, use by date, or an expiration date. The DM stead items that were expired should have been thrown out. The DM stated she did not know why the thickened liquids were still in the storage closet, it was used for a resident, but they quit using them. The DM stated dented cans should not be on shelf they should have been removed and discarded. The DM stated that food items should be sealed and not open to air. The DM stated what led to failure was she had been out on vacation for a few days. During an interview on 02/13/2023 at 12:20 PM DS C stated she normally wore gloves when serving food but did know why she did not put on gloves today. DS C stated she should have not picked up the toast with an ungloved hand. During an interview on 02/14/2023 at 10:55 AM the DM stated everyone who entered the kitchen should have placed a hair covering on their head and washed their hands. The DM stated hand hygiene should have occurred anytime a staff changed tasks or touched their face. The DM stated staff should have worn gloves when touching food that was ready to eat, such as the toast. The DM stated what led to failure of not using proper hand hygiene or wearing gloves was DS C must have been nervous. During an interview on 02/15/23 at 3:34 PM the ADMIN stated her expectation was that food be dated when received and/or with an open date, expired food items should have been discarded, and food items should be sealed and not open to air. The ADMIN stated the DM and herself were responsible to 675769 Page 6 of 9 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many ensure staff had properly stored and labeled food. The ADMIN stated the effect on residents could have received spoiled food. The ADMIN stated what led to failure was that she had not caught the items issues that needed to be corrected. The ADMIN stated her expectation of hand hygiene was that staff followed the protocols for hand hygiene. The ADMIN stated staff should have washed their hands when entered kitchen, after touched face, or changed tasks. The ADMIN stated staff should have worn gloves when they touched food that was ready to be served. The ADMIN stated anyone that entered the kitchen should have their hair covered. The ADMIN stated the effect on residents could have been food been contaminated with hair or spread of bacteria. The ADMN state what led to failure of not wearing hair coverings in kitchen was she did not think anyone was cooking and maintenance were excited to show her the new cabinet fronts. Review of CMS form 672 dated 2/15/2023 revealed 37 of 37 residents ate out of the kitchen. Review of the facility's policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices dated October 2017 revealed: Employees must wash their hands after personal body functions (i.e., toileting, blowing/ wiping nose, coughing, sneezing, etc ) . Whenever entering or reentering the kitchen . During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; And/or after engaging in other activities that contaminate the hands . Contact between food and bare (ungloved) hands is prohibited . Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Review of the facility's policy titled, Food Receiving and Storage dated December 2008 revealed, When food is delivered to the facility it will be inspected for safe transport and quality before being accepted . Dry foods that are stored in the refrigerator or freezer will be covered, labeled and dated (Use by date). All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). 675769 Page 7 of 9 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

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 maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 24 of 73 rooms reviewed for physical environment. Rms 309-315 did not have running water in bathrooms. Rms 309-316 did not have a mirror in the bathrooms. Rms 213 and 217 had no tile inside room and/or bathroom. Rm 213 and 217 had no functioning bathroom. Rms 102, 201, 218, 502, and 609, had obvious rust colored water damage to ceiling and/or holes in ceiling. Rm 311, 216 had no doorknob for the bathroom. Rm 314 had no door for the bathroom. These failures could place the residents in an unsafe and uncomfortable environment. Findings included: During an observation on 02/15/23 between 3:15PM and 4:15PM of resident rooms revealed the following: Rooms 309-316 had no bathroom mirrors. Rm 311 had no doorknob to the bathroom. Rm 314 had no door to the bathroom. Rm 315 was used as a chemical storage room, with the door unlocked, opened, and accessible to residents. Rm 201 was used as a storage room for beds with an obvious patch in ceiling with 2 other obvious larger areas of rust colored water damage in ceiling. Rm 213 had no floor tile in bathroom and no functioning toilet or sink. Rm 214 had no sink in bathroom and was used as a storage room. Rm 216 had no doorknob on bathroom door. Rm 217 had no tile on floor in room or bathroom. 675769 Page 8 of 9 675769 02/15/2023 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0921 Rm 218 had area of obvious water damage to ceiling. Level of Harm - Minimal harm or potential for actual harm Rm 102 had area of no ceiling rale for privacy curtain with obvious rust colored water damage on ceiling. Rm 607 had no running water in bathroom. Residents Affected - Some Rm 609 had no running water in bathroom and large area of obvious water damage to ceiling. Rm 502 had a large hole in the ceiling near bathroom door and closet door. During an interview with MM at 4:30PM on 02/15/23, he said the building had room damage in the last year and they were trying to fix the rooms. He said he had been the floor maintenance prior to taking over the supervisor position recently. MM said that there was no way possible that any single room that had damage or needed repairs could have been repaired and made ready for resident use within 24 hours. He said that he was aware that chemicals should not have been stored in the building in an unsecured room. MM said that it could be detrimental to a resident if they were to get into the chemicals stored in RM [ROOM NUMBER]. He said the nurses had keys to locked rooms [ROOM NUMBER]. He did not have any spare keys to be able to lock RM [ROOM NUMBER] with the chemicals stored in it. He stated residents could access Hall 300. During an interview with ADM on 02/15/23 at 5:25PM, she said she had been with the facility for approximately a year. She said she has been through the CHOW. ADM said they had a lot of roof damage last year but could not remember exactly when it happened that caused a lot of damage to ceilings in different areas of the facility. She said she was not sure if the facility notified HHSC of the need to repair and remodel the many rooms that had suffered damage. During a telephone interview with Co-Owner on 02/15/23 at 5:40PM, he said he knew there was an insurance claim for the repairs prior to his taking over ownership of the facility in May of 2022. He said he was not aware if there was notification to HHSC that many of the rooms would need to be repaired and/or remodeled prior to his ownership. Co-owner said that those rooms could not be used by residents at the present time. He said he did not have an expected date of completion for all the repairs needed for those resident rooms. Record Review of Facility Policy labeled Quality of Life-Homelike Environment revised 05/2017 revealed: Residents are provided with a safe, clean, comfortable and home like environment . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include: clean, sanitary and orderly environment 675769 Page 9 of 9