Health inspection·April 30, 2025

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 7 (Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #10, Resident #16) of 12 residents reviewed for MDS assessments. Residents Affected - Some The facility failed to complete Resident #3's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #4's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #5's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #7's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #8's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #10's Quarterly MDS Assessment within 14 calendar days of the ARD. The facility failed to complete Resident #16's Quarterly MDS Assessment within 14 calendar days of the ARD. This failure could lead to residents not receiving the care required to meet their individual needs. Findings included: Record review of Resident #3's admission Record revealed Resident #3 was originally admitted on [DATE] with a most recent admission date of 12/08/2020. The admission Record indicated a [AGE] year-old male with medical diagnoses of intellectual disabilities, anxiety disorder, high blood pressure, suicidal ideations, high blood cholesterol, overweight, heart disease, and a chronic lung disorder. Review of Resident #3's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, Page 1 of 16 675769 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some subsection C0500 BIMS Score Summary, the resident scored 11 out of 15 indicating mild cognitive impairment. Further review of Resident #3's Quarterly MDS revealed an ARD/Target Date of 02/10/25. The Record review of Resident #4's admission Record revealed Resident #4 was originally admitted on [DATE] with a most recent admission date of 06/15/2021. The admission Record indicated a [AGE] year-old female with medical diagnoses of intellectual disabilities, pseudobulbar affect (a neurological condition characterized by sudden, involuntary episodes of crying or laughing, often in a response to a situation that is not emotional), high blood pressure, Type 2 diabetes mellitus, anxiety disorder, weakness, and major depressive disorder (a mood disorder characterized by persistent sadness and loss of interest in activities). Review of Resident #4's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 10 out of 15 indicating mild cognitive impairment. Further listed on the Quarterly MDS was 04/17/2025. Record review of Resident #5's admission Record revealed Resident #5 was admitted on [DATE]. The admission Record indicated a [AGE] year-old female with medical diagnoses of Type 2 diabetes mellitus, high blood cholesterol, high blood pressure, alcohol dependence, heart disease, dementia, major depressive disorder, anxiety, and nightmare disorder. Review of Resident #5's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 12 out of 15 indicating mild cognitive impairment. Further on the Annual MDS was 04/17/2025. Record review of Resident #7's admission Record revealed Resident #7 was admitted on [DATE]. The admission Record indicated a [AGE] year-old male with medical diagnoses of bacteremia (bacteria in the urine), cirrhosis of the liver (liver tissue is replaced with scar tissue), anemia, acute kidney failure, rhabdomyolysis (damaged muscle tissue releases its contents into the bloodstream which could lead to kidney damage ), dyspnea (difficulty breathing), dizziness, high blood pressure, insomnia, weakness, and unsteady when walking. Review of Resident #7's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 12 out of 15 indicating mild cognitive impairment. Further listed on the Quarterly MDS was 04/17/2025. Record review of Resident #8's admission Record revealed Resident #8 was originally admitted on [DATE] with a most recent admission date of 02/18/2023. The admission Record indicated a [AGE] year-old male with medical diagnoses of intellectual disabilities, cerebral palsy (a group of neurological disorders that affect movement, posture, and muscle tone), paraplegia (paralysis that affects the lower half of the body), high blood pressure, high blood cholesterol, major depressive disorder, Type 2 diabetes mellitus, heartburn, weakness, bladder dysfunction, insomnia, Barrett's esophagus without dysplasia (a condition when the lining of the esophagus becomes more like the lining of the intestines due to exposure to stomach acid), and arthritis. Review of Resident #8's Annual MDS dated [DATE] revealed in Section C Cognitive Patterns, 675769 Page 2 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some subsection C0500 BIMS Score Summary, the resident scored 4 out of 15 indicating severe cognitive impairment. Further review of Resident #8's Annual MDS, revealed an ARD/Target Date of 01/17/25. The Record review of Resident #10s admission Record revealed Resident #10 was originally admitted on [DATE] with a most recent admission date of 10/24/2021. The admission Record indicated an [AGE] year-old female with medical diagnoses of dementia, low blood potassium, weakness, high blood pressure, anxiety, malnutrition, history of falls, and low thyroid function. Review of Resident #10's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 11 out of 15 indicating mild cognitive impairment. Further review of Resident #10's Quarterly MDS, revealed an ARD/Target Date of 02/05/25. Record review of Resident #16's admission Record revealed Resident #16 was admitted on [DATE]. The admission Record indicated a [AGE] year-old male with medical diagnoses of lung cancer, high blood pressure, anxiety, insomnia, heart failure, heart disease, chronic lung disease, schizoaffective disorder (A condition characterized by a combination of symptoms from schizophrenia and mood disorders), arthritis, amputation of right leg above the knee, chronic pain, heartburn, and constipation. Review of Resident #16's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 14 out of 15 indicating intact cognition. Further review of Resident #16's Quarterly MDS, revealed an ARD/Target Date of 02/22/25. The completion date listed on the Quarterly MDS was 04/17/2025. During an interview on 04/30/25 at 12:45 PM, the DON stated the MDS nurse was responsible for completing and updating the MDS. She stated she did not know why failing to complete the MDS on time occurred. She stated it was ultimately her responsibility to ensure that everything was completed but she just started this position and was playing catch up. During an interview on 04/30/25 at 12:50 PM, the Administrator stated the delay in completing the MDS's was due to the facility going through transition during a change of ownership. She stated the MDS Coordinator was responsible for preparing the MDS. The Administrator explained the MDS Coordinator covered 3 buildings and was in the process of transferring all residents to new identification numbers. She stated she was aware that MDS's were late. The Administrator stated her expectation was for MDS's to be complete and submitted on time. She stated the person responsible for monitoring MDS's was a corporate nurse. The Administrator stated she did not think failing to complete MDSs on time would directly affect the residents. She stated possible indirect effects because the facility did not get paid until the MDSs were submitted. During an interview on 04/30/25 at 01:26 PM, the MDS Coordinator stated she was responsible for entering data and transmitting MDS's. She explained MDS's were not completed timely because the facility did not have a DON until recently. She stated the MDSs were not currently being transmitted due to the change in ownership process. The MDS Coordinator stated she was told by corporate not to transmit until the PL1 (assignment of new facility ID and providers number) process was complete. She stated her expectation, under normal circumstances, was to finish an MDS as soon as the ARD hits. The MDS Coordinator stated she had done MDSs for 12 years and was unable to state any effect on residents in failing to complete or transmit MDS's timely. 675769 Page 3 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 04/30/25 at 02:12 PM, the Administrator clarified a PL1 was tasks corporate took care of to be assigned new identifying numbers. She stated MDSs were being kicked back due to incorrect identifying numbers because the change in ownership process was not complete. Review of facility policy titled MDS Completion and Submission Timeframes, revised July 2017, revealed Policy Statement Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation 2. Timeframes for completion and submission of assessment is based on the current requirements published in the Resident Assessment Instrument Manual. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.1.9.1 dated October 2024 revealed in Chapter 2 Assessments for the Resident Assessment Instrument; section 2.6 Required OBRA Assessments for the MDS; subsection 05 Quarterly Assessment (A0320A = 02) The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be after the ARD (ARD + 14 calendar days). 675769 Page 4 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 (Resident #2) of 12 residents reviewed for baseline care plans. The facility failed to ensure that Resident #2 had baseline care plan developed within 48 hours after being admitted to the facility on [DATE]. These failures placed the residents at risk of not having continuity of care to safeguard against adverse events that are most likely to occur right after admission. Findings included: Review of Resident #2's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, chronic pulmonary disease, emphysema. Review of Resident #2's admission MDS assessment, dated 12/15/24, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Section O reflected Resident #1 was on continuous oxygen. Review of Resident #2's facility records reflected no evidence of a baseline care plan. During an interview on 04/30/25 at 12:45 PM, the DON stated that Resident #2 should have had a new baseline care plane when she readmitted in December. She stated that the admitting nurse was responsible for completing the baseline care plan. She stated she did not know why this failure occurred. She stated it was untimely her responsibility to ensure that everything was completed but she just started this position and was playing catch up. Record review of facility policy labeled Care Plans-Baseline dated 20001 reflected: a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. 675769 Page 5 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #11, Resident #70) of 14 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for hospice services for Resident #11. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for Oxygen use for Resident #70. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Record review of Resident #11's electronic face sheet 04/30/2025 revealed [AGE] year-old male admitted [DATE] and diagnosis included Chronic Obstructive Pulmonary Disease (lung disease), Unspecified Dementia, Hypertension (high blood pressure), Seizures (sudden temporary disruption of brain activity) Record review of Resident #11's Physician Orders dated 04/30/24 revealed hospice to evaluate and treat if appropriate. Record review of Resident #11's significant change MDS dated [DATE] revealed Cognitive Patterns, Resident #11's BIMS (Brief Interview of Mental status) score 12 (moderated cognitive impairment) Special Treatments, Procedures, and Programs-Hospice care. Record review of Resident #11's Care Plan dated 02/18/2025 revealed no documented Focus, Goal, or Interventions for hospice care for Resident #11. Record review of Resident #70's electronic face sheet on 04/30/2025 revealed [AGE] year-old male admitted [DATE] with diagnosis that included Secondary Malignant Neoplasm (abnormal growth of cells, tumor) of Bone, Hypertension (high blood pressure), Unspecified Dementia, Chronic Pain. Record review of Resident #70's hospice orders dated 03/06/2025 revealed no physician order for oxygen use. Record review of Resident # 70's admission MDS dated [DATE] revealed Cognitive Patterns- Resident #70's BIMS score 03-severe cognitive impairment. Record review of Resident #70's Care Plan dated 04/29/2025 revealed no documented Focus, Goal, Interventions for oxygen use. 675769 Page 6 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #70's Physician orders dated 04/30/2025 revealed no physician order for oxygen use. During an observation on 04/28/2025 at 10:20 AM Resident #70 was lying in bed with oxygen via nasal cannula at 5 LPM in place. Residents Affected - Some During an observation on 04/28/2025 at 02:06 PM Resident #11 had oxygen at 4 LPM vis nasal cannula in place. Oxygen in use sign outside Resident #11's door. During an observation on 04/29/2025 at 11:15 AM Resident #70 lying in bed with oxygen via nasal cannula at 5 LPM in place. Resident #70's room did not have an oxygen in use sigh posted. During an interview on 04/30/2025 at 01:26 PM with MDS Coordinator stated she was responsible for participating in care plan development. The MDS Coordinator stated she did not know how the failure occurred for residents to not have complete comprehensive care plan. The MDS Coordinator was unable the state effect on residents in failing to ensure care plans included all serviced provided to resident. During an interview on 04/30/2025 at 2:00 PM The DON stated oxygen use should be care planned. The DON stated the effect on resident not having oxygen care planned would be that the staff may not know resident needed to have the oxygen. The DON stated she did not know how this failure occurred. The DON stated MDS Coordinator was responsible for initiating care plans. The DON stated she was responsible for checking care plans quarterly and when a resident had a change in condition that required additional interventions on care plan. 04/30/2025 at 03:10 PM at time of exit there had been no return call from MDS Coordinator. Record review of facility's policy titled Comprehensive Care Planning (not dated) revealed.: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following--The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being; and Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and addresses the resident's medical, physical, mental and psychosocial needs The comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment . The facility will ensure that services provided or arranged are delivered by individuals who have the skills, experience, and knowledge to do a particular task or activity. This includes proper licensure or certification if required. 675769 Page 7 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 (Resident #2 Resident #70) of 3 residents reviewed for respiratory care. Residents Affected - Some 1. The facility failed to obtain a Physician's order for Resident #2's continuous supplemental oxygen. 2. The facility failed to obtain a Physician's order for Resident #70's continuous supplemental oxygen. 3. The facility failed to post oxygen in use sign for Resident #70. These failures could place residents at risk of not receiving the necessary respiratory care to meet their needs. Findings included: Record review of Resident #2's electronic face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, chronic pulmonary disease, emphysema. ( Lung disease) Record review of Resident #2's admission MDS assessment, dated 12/15/24, reflected a BIMS score of 15 which indicated no cognitive impairment. Review of Section O reflected Resident #1 was on continuous oxygen. Record review of Resident #2's facility records reflected no evidence of a comprehensive care plan or a baseline care plan. During observation and interview on 04/28/25 at 02:06 PM, Resident #2 sitting up in bed doing a crossword puzzle. She stated she is here for therapy and has no concerns. Resident #2 was on oxygen at 4LPM via nasal cannula and an oxygens sign was observed outside of her door. Record review of Resident #2's electronic physicians orders reflected no evidence of an order for oxygen. Record review of Resident #70's on 04/30/2025 electronic face sheet revealed [AGE] year-old male admitted [DATE] with diagnosis that included Secondary Malignant Neoplasm (abnormal growth of cells, tumor) of Bone, Hypertension (high blood pressure), Unspecified Dementia, Chronic Pain. 675769 Page 8 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0695 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #70's Physician orders dated 04/30/2025 revealed no physician order for oxygen use . Record review of Resident #70's hospice orders dated 03/06/2025 revealed no physician order for oxygen use. Residents Affected - Some Record review of Resident # 70's admission MDS dated [DATE] revealed Cognitive Patterns- Resident #70's BIMS score 03-severe cognitive impairment. Record review of Resident #70's Care Plan dated 04/29/2025 revealed no documented Focus, Goal, Interventions for oxygen use. During an observation on 04/28/2025 at 10:20 AM Resident #70 was lying in bed with oxygen via nasal cannula at 5 LPM in place. Resident #70's room did not have an oxygen in use sign posted. During an observation on 04/29/2025 at 11:15 AM Resident #70 lying in bed with oxygen via nasal cannula at 5 LPM in place. Resident #70's room did not have an oxygen in use sigh posted. During an interview on 04/30/2025 at 2:00 PM the DON stated there should have been an order for any resident with oxygen and there should have been a sign outside the resident's room stating that oxygen was in use. The DON stated she did not think the resident was affected due to the resident was receiving the needed oxygen. The DON stated she did not know how this failure occurred. The DON stated she was responsible for checking the physician's orders for accuracy. 04/30/2025 at 03:10 PM at time of exit there had been no return call from MDS Coordinator regarding comprehensive care plans. Record review of facility's policy titled Oxygen Administration (no date) revealed: Purpose The purpose of this procedure is to provide guideline for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed Equipment and Supplies 675769 Page 9 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0695 1. Level of Harm - Minimal harm or potential for actual harm Portable oxygen cylinder (strapped to the stand); 2. Residents Affected - Some Nasal cannula, nasal catheter, mask (as ordered) 3. Humidifier bottle 4. No Smoking/Oxygen in Use signs . 675769 Page 10 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #10, Resident #127, and Resident #147) of 12 residents reviewed for unnecessary medications. The facility failed to ensure Resident #10's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #127's PRN Alprazolam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #147's PRN Lorazepam (medicine used to treat the symptoms of anxiety) and Haloperidol (medicine used to treat agitation) was discontinued after 14 days or a documented rational for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms and dependence on unnecessary medications. Findings included: Resident # 10 Review of Resident #10's electronic face sheet revealed resident was an [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and high blood pressure. Review of Resident #10's Quarterly MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 12 (no cognitive impairment); Section N- Medication's resident received Antianxiety medication in the last 7 days of review period. Review of Resident #10's Comprehensive Care Plan last revised 10/25/2021, revealed: Focus: Resident uses anti-anxiety medications r/t anxiety disorder. Goal: Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions: Administer anti-anxiety medications as ordered by physician . Review of Resident #10's electronic physician orders revealed: Lorazepam Oral tablet 1 mg give 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 10/20/2024 and no end date and Lorazepam Concentrate 2 MG/ML Give 0.5 ml by mouth every 6 hours as needed for anxiety with a start date of 08/02/2024 and no end date. Review of Resident #10's physician progress notes from January 2025- April 2025 revealed no documented rationale for the continued provision of Lorazepam. 675769 Page 11 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #10's electronic MAR for April 2025 revealed 7 doses of Lorazepam oral tablet had been administered and Lorazepam Concentrate 1 dose had been administered. Review of Drugs.com for Lorazepam accessed on 04/29/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Resident #127 Review of Resident #127's electronic face sheet revealed resident was an [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE], with diagnoses that included: Anxiety, Diabetes, and high blood pressure. Review of Resident #127's admission MDS dated [DATE] revealed: Section C- Cognitive Patterns a BIMS score of 15 (no cognitive impairment); Section N- Medication's resident received Antianxiety medication 0 days out of the last 7 days of review period. Review of Resident #127's Baseline Care Plan dated 04/25/2025, revealed resident was not taking any PRN psychotropic medications. Review of Resident #127's electronic physician orders revealed: Alprazolam tablet 0.25 mg Give 1 tablet by mouth every 8 hours as needed for Anxiety with a start date of 04/11/2025 and no end date. Review of Resident #127's physician progress notes from April 2025 revealed no documented rationale for the continued provision of alprazolam. Review of Resident #127's electronic MAR for April 2025 revealed no doses of Alprazolam had been administered for anxiety. Review of Drugs.com for Alprazolam accessed on 04/29/2025 at https://www.drugs.com/alprazolam.html revealed: Alprazolam is a benzodiazepine. It is thought that it works by enhancing the activity of certain neurotransmitters in the brain. Alprazolam is used to treat anxiety disorders, panic disorders, and anxiety caused by depression. Resident # 147 Review of Resident #147's electronic face sheet revealed resident was an [AGE] year-old female who was admitted on [DATE] with diagnoses that included: Dementia, Anxiety, and high blood pressure. Review of Resident #174's Quarterly MDS dated [DATE], reflected a BIMS score of 03 which indicated severe cognitive impairment. Review of Resident #174's Comprehensive Care Plan last revised 07/29/2024, reflected: Focus: resident has a mood problem r/t agitation. Goal: resident will have improved mood state. Interventions: Administer medications as ordered . Review of Resident #147's electronic physician orders revealed: Lorazepam Oral tablet 1 mg give 1 tablet by mouth every 4 hours as needed for anxiety with a start date of 09/18/2024 and no end date 675769 Page 12 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0758 Level of Harm - Minimal harm or potential for actual harm and Haloperidol Lactate Oral Concentrate 2 MG/ML Give 0.5 ml by mouth every 6 hours as needed for agitation with a start date of 02/05/2025 and no end date. Review of Resident #147's physician progress notes from January 2025- April 2025 revealed no documented rationale for the continued provision of Lorazepam or Haloperidol. Residents Affected - Some Review of Resident #147's electronic MAR for April 2025 revealed 0 doses of Lorazepam oral tablet had been administered and Haloperidol 3 doses had been administered. Review of Drugs.com for Lorazepam accessed on 04/29/2025 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. Review of Drugs.com for Haloperidol accessed on 04/29/2025 at https://www.drugs.com/haloperidol.html revealed: Haloperidol is the first of the butyrophenone series of major antipsychotics. More common side effects difficulty with speaking or swallowing, inability to move the eyes, and loss of balance control. During an interview on 04/30/25 at 12:45 PM, the DON stated that all prn psychotropic medications should have a 14 day stop date and a physician should reevaluate if the medication is needed longer and re-order. She stated the floor nurses were responsible for entering orders when they were received and that currently no one was reviewing or verifying new orders. She stated it was ultimately her responsibility to ensure that orders were entered correctly and that the prn psychotropics have a 14 day stop date. She stated this failure could lead to residents receiving unnecessary medications. She stated this failure possibly occurred due to change in staff and not having a DON in the facility until recently. She stated that the ADON had been responsible for reviewing and completing the pharmacy recommendations. She stated the failure of not completing the recommendations probably occurred due to not having a DON and the ADON having too many responsibilities. Review of facility policy titled; Psychotropic Medication Use dated 2001 revealed in part: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation: .12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. 675769 Page 13 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 2 (Resident #15 and Resident #174) of 12 residents reviewed for medications. Residents Affected - Some The facility failed to hold Carvedilol (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 15 doses in April 2025 for Resident #15. The facility failed to hold Lisinopril (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 5 doses in April 2025 for Resident #15. The facility failed to hold Midodrine (medication to increase blood pressure) per parameters stated in physicians' orders for a total of 19 doses in April 2025 for Resident #15. The facility failed to administer Clonidine (medication to lower blood pressure) per parameters stated in physicians' orders for a total of 31episodes of high blood pressure in April 2025 for Resident #174. The deficient practice placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: Resident #15 Review of Resident #15's electronic face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: high blood pressure, respiratory failure, and kidney failure. Review of Resident #15's Quarterly MDS dated [DATE], reflected a BIMS score of 06 which indicated severe cognitive impairment. Review of Resident #15's Comprehensive Care Plan last revised 10/13/2024, reflected: Focus: Hypertension: resident has a potential for fluctuations in blood pressure, low blood pressure and high blood pressure. Goal: residents blood pressure will stay within normal limits and will not have signs or symptoms of low or high blood pressure. Interventions: .Give medications per order-monitor labs- report results to doctor . Review of Resident #15's electronic physicians' orders reflected: Carvedilol Oral Tablet 3.125 MG Give 1 tablet by mouth two times a day for hypertension Hold for SBP (top number of blood pressure) less than 110, order date 01/09/2025. Review of Resident #15's electronic MAR for April 2025 reflected carvedilol was given on: 4/4/25 at 9pm for BP of 103/56 by LVN A, 4/5/25 at 9am for BP of 109/55 by LVN B, 4/5/25 at 9pm for BP of 103/53 by LVN A, 4/9/25 at 9am for BP of 105/62 by ADON, 4/9/25 at 9pm for BP of 107/61 by LVN C, 4/10/25 at 9pm for BP of 101/62 by DON, 04/12/25 at 9am for BP of 104/64 by LVN D, 04/12/25 at 9pm for BP of 101/73 by LVN E, 4/14/25 at 9am for BP of 86/62 by ADON, 04/14/25 at 9pm for BP of 86/62 by LVN C, 4/15/25 at 9am for BP of 86/62 by ADON, 4/15/25 at 9pm for BP of 91/60 by LVN C, 4/16/25 at 9pm 675769 Page 14 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for BP of 102/62 by LVN E, 4/18/25 at 9pm for BP of 100/73 by LVN C, and 4/28/25 at 9pm for BP of 97/65 by LVN C. Review of Resident #15's electronic physicians' orders reflected: Lisinopril Oral Tablet 2.5 MG Give 1 tablet by mouth in the morning for hypertension Hold for SBP (top number of blood pressure) less than 110, order date 01/09/2025. Review of Resident #15's electronic MAR for April 2025 reflected lisinopril was given on: 4/5/25 at 9am for BP of 109/55 by LVN B, 4/9/25 at 9am for BP of 105/62 by ADON, 04/12/25 at 9am for BP of 104/64 by LVN C, 4/14/25 at 9am for BP of 86/62 by ADON, and 4/15/25 at 9am for BP of 86/62 by ADON. Review of Resident #15's electronic physicians' orders reflected: Midodrine Oral Tablet 2.5 MG Give 1 tablet by mouth two times a day for low blood pressure Hold for SBP (top number of blood pressure) greater than 110, order date 01/09/2025. Review of Resident #15's electronic MAR for April 2025 reflected Midodrine was given on: 4/4/25 at 9am for BP of 120/64 by RN G, 4/6/25 at 9am for BP of 113/61 by LVN B, 4/6/25 at 9pm for BP of 121/60 by ADON, 4/7/25 at 9am for BP of 117/74 by LVN A, 4/8/25 at 9am for BP of 112/64 by LVN A, 4/13/25 at 9am for BP of 130/80 by LVN F, 4/17/25 at 9am for BP of 121/65 by LVN F, 4/19/25 at 9am for BP of 116/64 by LVN A, 4/19/25 at 9pm for BP of 136/73 by LVN C, 4/20/25 at 9am for BP of 136/73 by LVN F, 4/20/25 at 9pm for BP of 115/66 by LVN C, 4/21/25 at 9am for BP of 115/64 by ADON, 4/23/25 at 9pm for BP of 136/99 by LVN C, 4/24/25 at 9pm for BP of 121/97 by LVN C, 4/25/25 at 9am for BP of 136/61 by LVN F, 4/26/25 at 9am for BP of 120/71 by RN H, 4/26/25 at 9pm for BP of 120/71 by LNV E, 4/27/25 at 9am for BP of 120/71 by RN H, 4/27/25 at 9pm for BP of 128/74 by LVN E. Resident #174 Review of Resident #174's electronic face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, dementia, and high blood pressure. Review of Resident #174's Quarterly MDS dated [DATE], reflected a BIMS score of 03 which indicated severe cognitive impairment. Review of Resident #174's Comprehensive Care Plan last revised 07/29/2024, reflected: Focus: resident has hypertension. Goal: resident will remain free for signs or symptoms of high blood pressure. Interventions: .Give anti-hypertensive medications as ordered . Review of Resident #174's electronic physicians' orders reflected: Clonidine Oral Tablet Give 0.1 mg by mouth every 8 hours as needed for SBP (top number of blood pressure) over 160, order date 02/05/2025. Review of Resident #174's electronic Blood Pressure Flow Sheet reflected: 04/01/25 at 10:04 am BP 194/98, 04/01/25 at 6:21 pm BP 173/90, 04/02/25 at 7:38 am BP 192/113, 04/03/25 at 6:22 am BP 168/94, 04/05/25 at 6:18 am BP 177/83, 04/07/25 at 6:29 am BP 188/98, 04/08/25 at 6:19 am BP 183/110, 04/08/25 at 6:10 pm BP 196/106, 04/09/25 at 6:27 am BP 179/99, 04/09/25 at 6:12 pm BP 180/94, 04/10/25 at 6:06 am BP 177/97, 04/10/25 at 6:24 pm BP 171/88, 04/11/25 at 7:03 am BP 179/97, 04/11/25 at 7:49 pm BP 171/84, 04/12/25 at 8:46 am BP 181/84, 04/13/25 at 6:47 am BP 184/96, 04/16/25 at 6:31 am BP 164/83, 04/18/25 at 6:15 am BP 169/88, 04/18/25 at 6:34 pm BP 175/93, 04/19/25 at 9:31 am BP 195/94, 04/19/25 at 6:19 pm BP 176/90, 04/20/25 at 7:06 am BP 186/93, 04/20/25 at 6:23 pm BP 166/93, 04/23/25 675769 Page 15 of 16 675769 04/30/2025 Harmony Care at Stamford 1003 Columbia Stamford, TX 79553

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at 6:10 am BP 175/91, 04/23/25 at 6:56 pm BP 169/91, 04/24/25 at 6:27 am BP 189/96, 04/24/25 at 6:16 pm BP 170/98, 04/28/25 at 6:24 am BP 182/99, 04/28/25 at 6:18 pm BP 161/87, 04/29/25 at 6:38 am BP 187/98, 04/29/25 at 6:38 am BP 187/98. Review of Resident #174's electronic MAR for April 2025 reflected clonidine was not given on: 04/01/25 at 10:04 am BP 194/98, 04/01/25 at 6:21 pm BP 173/90, 04/02/25 at 7:38 am BP 192/113, 04/03/25 at 6:22 am BP 168/94, 04/05/25 at 6:18 am BP 177/83, 04/07/25 at 6:29 am BP 188/98, 04/08/25 at 6:19 am BP 183/110, 04/08/25 at 6:10 pm BP 196/106, 04/09/25 at 6:27 am BP 179/99, 04/09/25 at 6:12 pm BP 180/94, 04/10/25 at 6:06 am BP 177/97, 04/10/25 at 6:24 pm BP 171/88, 04/11/25 at 7:03 am BP 179/97, 04/11/25 at 7:49 pm BP 171/84, 04/12/25 at 8:46 am BP 181/84, 04/13/25 at 6:47 am BP 184/96, 04/16/25 at 6:31 am BP 164/83, 04/18/25 at 6:15 am BP 169/88, 04/18/25 at 6:34 pm BP 175/93, 04/19/25 at 9:31 am BP 195/94, 04/19/25 at 6:19 pm BP 176/90, 04/20/25 at 7:06 am BP 186/93, 04/20/25 at 6:23 pm BP 166/93, 04/23/25 at 6:10 am BP 175/91, 04/23/25 at 6:56 pm BP 169/91, 04/24/25 at 6:27 am BP 189/96, 04/24/25 at 6:16 pm BP 170/98, 04/28/25 at 6:24 am BP 182/99, 04/28/25 at 6:18 pm BP 161/87, 04/29/25 at 6:38 am BP 187/98, 04/29/25 at 6:38 am BP 187/98. During an interview on 04/30/25 at 12:45 PM, the DON she stated she expected her nurses to follow physicians' orders. She stated she expected her nurses to read the MAR and follow parameters. She stated any component nurse should have identified a low or high blood pressure and then looked at the orders to see the parameters. She stated the failure was probably caused by nurses not paying attention. The DON stated that anytime a resident's blood pressure was high she would expect them to look to see if the resident had any standing PRN orders. She stated not following the parameters could lead to residents not receiving the proper treatment for their blood pressures which could lead to pressures not being controlled. During an interview on 04/30/25 at 01:04 PM, the Medical Director stated he just took over this facility and he was unsure why Resident #15 was on medications to decrease and increase his blood pressure. He stated that it was his expectation for nurses to follow the parameters set in the physician's orders. He stated Lisinopril and Carvedilol should never be given at the same time as Midodrine because they will counteract each other. He stated he did not feel that this would have too negative of an outcome. He stated not holding the BP medications could cause the residents blood pressure to get too low, but Resident #15 had not had any issues as of now. He stated PRN blood pressure medications should always be given if ordered when a resident has a high blood pressure. He stated this could lead to residents' blood pressure not being controlled adequately. He stated he did not expect to be notified every time a medication is held, or a PRN was given unless it was a substantial change in condition. During an interview on 04/30/25 at 1:20 PM, the Administrator stated she expected her staff to following physicians' orders and to be competent enough to notice a high or low blood pressure and to check the orders for parameters. She stated the failure probably occurred because of nurses not paying attention. The Administrator stated she was unable to find a policy regarding medication administrator or following physicians' orders. 675769 Page 16 of 16