Inspection·July 13, 2022

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #20's physician's orders, dated July 2022, revealed, in part, .order date 4/20/22 .Psychotic disorder w hallucin due to known physiol con [sic] . Record review of document in Resident #20's chart titled, Consent for Antipsychotic or Neuroleptic Medication Treatment, dated 04/20/22, revealed, in part, .Residents Name [Resident #20] .I believe the individual has the following psychiatric condition and/or maladaptive behavior: hallucinations .The need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medications(s) is indicated: Amelioration of psychosis . Record review of Resident #20's electronic chart with ADON revealed, in part, Resident Basic Information .Psychotic disorder with hallucinations due to [sic] .Onset 2/28/22. During an observation and interview on 07/11/22 at 3:00 PM, Resident #20 was sitting in a wheelchair with a chair alarm attached to her and a head protector pad wrapped around her head. Resident #20 would mumble indecipherable words with decipherable words spoken intermittently. During the conversation, the only decipherable terms were husband and die here and retirement. During an interview and record review on 07/13/22 at 2:30 PM with ADON, she confirmed that she was responsible for submitting PASARR information. She stated Resident #20 was admitted on [DATE] and when asked when Resident #20 was diagnosed with a psychotic disorder, ADON found on her computer, on the electronic health record, the diagnosis dated 02/28/22. ADON stated she knew PASARR qualifying diagnoses included mental health diagnoses, mental retardation or Down Syndrome, but otherwise she did not know what additional PASARR qualifying diagnoses were. She stated she did not know psychotic disorder was a PASARR qualifying diagnosis. She stated that when residents were admitted to the facility, they usually had very little information on them since most of the time they were being admitted from home. She stated Resident #20 had not visited a doctor in six years prior to her admission to the facility and herself and her family were very poor historians. ADON stated she did not know that a PASARR Level 1 had to be resubmitted if a resident was diagnosed with a qualifying diagnosis after their initial admission PASARR. She stated that the PASARR responsibility got thrown on her when the new Business Office Manager started a few years ago; the previous Business Office Manager was responsible for PASARR information before. ADON stated she did not receive PASARR training. She stated a potential negative consequence for PASARR information not being addressed correctly could be a resident could have been a danger to themselves or others. Record review of Resident #27's face sheet, dated 06/01/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included unspecified dementia, Alzheimer's disease with late onset, personality change due to known physiological condition. The face sheet also contained a second sheet, dated 06/01/22, with additional current diagnoses of psychotic disorder with delusions due to known physiological condition (a mental health problem that causes people to perceive or interpret things differently from those around them that might involve hallucinations or delusions). Record review of Resident #27's Quarterly MDS, dated [DATE], revealed a BIMS score could not be conducted. Section E of the MDS titled, Behavior revealed, in part, .Psychosis: Hallucinations .Checked .Psychosis: Delusions .Checked. Section G titled, Functional Status revealed Resident #20 required full staff performance with bed mobility, locomotion, dressing, eating, transferring, toilet use and personal hygiene. Section I titled, Active Diagnoses revealed diagnoses of anxiety, depression (other than bipolar), schizophrenia, post-traumatic stress disorder (PTSD), and psychotic disorder (other than schizophrenia). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 2 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 Record review of Resident #27's care plan, dated 05/29/2021, revealed in part, [Resident #27] has varying mental function with inattention and disorganized thinking related to relocation. Interventions include observe for changes in mental status, encourage verbalization, approach resident warmly and positively, encourage resident to participate in activities. Resident 27's care plan also revealed in part, [Resident 27] has impaired communication associated with decline in cognitive status, delirium/disorganized thinking. Interventions include ask resident questions that require one- or two- word answers, face resident when speaking to resident, remove as much background noise as possible when speaking with resident. Record review of Resident #27's PASARR Level 1, dated 05/ 31/2021, revealed, in part, Is there evidence or an indicator this is an individual that has a Mental Illness? No . Is there evidence or an indicator this is an individual that has an Intellectual Disability? No . Is there evidence or an indicator this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability (e.g., Autism, Cerebral Palsy, Spina Bifida)? No. Record review of Resident #27's PASARR Level 1, dated 05/5/2022, revealed, in part, Is there evidence or an indicator this is an individual that has a Mental Illness? No . Is there evidence or an indicator this is an individual that has an Intellectual Disability? No . Is there evidence or an indicator this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability (e.g., Autism, Cerebral Palsy, Spina Bifida)? No. Record review of document in Resident #27's chart titled, [physician name] [facility name] Diagnostic Evaluation, dated 07/01/2021, revealed, in part, DSM Diagnostic Impression: AXIS 1: 1. F06.2 Psychotic disorder with delusions due to known physiological condition 2. F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance 3. F41.9 Anxiety disorder, unspecified During an interview with DON on 7/12/2022 at 2:22 PM, she stated Resident #27 was admitted [DATE]. DON stated the initial diagnosis of psychotic disorder with delusions due to known physiological condition was dated on 07/01/2022. She stated that there was no other PASARR done at the time of the new qualifying diagnosis. DON stated she did not know why it was not done. She stated the ADON would be the one who knows about the PASARR information because she handles PASARR information. During an interview with ADON on 7/13/2022 at 03:32 PM, she stated she did not have a PASARR policy. ADON stated she is the one who has been submitting PASARR information for the past few years after the previous Business Office Manager left the facility. ADON stated she did not receive training (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 3 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 for PASARR. She stated she did not know that a PASARR Level 1 needed to be resubmitted if a resident was diagnosed with a qualifying diagnosis after their initial admission PASARR. ADON stated a potential negative consequence for PASARR would be that the resident could be missing out on services according to their diagnosis. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 4 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan consistent with resident rights, that include measurable objectives and time frames to meet resident's mental and psychosocial needs for one of 13 residents (Resident #9) reviewed for accurate care plans. The facility failed to develop a comprehensive person-centered care plan to address Resident #9's Type 2 Diabetes mellitus with hyperglycemia. This failure could place the resident at risk for not having their person-centered needs met. Findings included: Record review of Resident #9's face sheet revealed a [AGE] year-old female resident re-admitted to the facility on [DATE] with a diagnosis to include Type 2 Diabetes mellitus with hyperglycemia. Record review of Resident #9's Quarterly MDS, dated [DATE], revealed a BIMS score could not be completed resident is rarely/never understood and had a functionality of requiring one-person assistance with most activities. Section C titled, Cognitive Patterns revealed the staff assessment of short and long-term memory problem and did not have memory/ability recall. The cognitive skills for daily decision making was checked for moderately impaired-decisions poor, cues/supervision required. Section G titled, Functional Status revealed Resident #9 required extensive support and with one person assist with ADL's. Section I of the MDS titled Active diagnoses revealed a diagnosis of diabetes mellitus. Record review of Residents #9's facility provided care plans dated 08/12/2020; 04/06/2021; and 12/08/2021 revealed no care plans to address Diabetes mellitus. During an interview on 07/13/2022 at 07:53 PM the DON verified the facility did not complete a care plan to include Diabetes mellitus in any of the care plans completed for Resident #9. The DON confirmed that there was not a care plan completed after the 04/05/2022 MDS quarterly review. DON reported that she was currently updating a new care plan. DON revealed the DON was responsible for updating the care plans. DON confirmed that Resident #9 did have a diagnosis of Diabetes. When asked if Diabetes mellitus was in the any of the care plans for Resident #9, DON stated It should be in here. No reason should not be that she knows of. When asked when the diagnoses of Diabetes was made DON stated at admission. When asked what would happen if the care plan did not include something, DON stated the resident possibly would not receive the care needed and staff may not know to monitor the condition. During an interview on 07/13/2022 at 08:10 PM the ADON stated that the DON is the person to update all Resident care plans. She stated the information is in the MDS when it is completed to include all information in the care plans. She stated that care plans are updated when a significant change is made or after the MDS is updated. Record review of facility provided policy titled, Care Area Assessments with a revision date of 11-2019 revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 5 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 Policy Statement Level of Harm - Minimal harm or potential for actual harm -Care area assessments (CAAs) are used to help analyze data obtained from the MDS and to develop individualized care plans. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 6 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for one of 13 residents (Resident #9) reviewed for care plan timing. - The facility failed to update the comprehensive person-centered care plans to address resident's needs after MDS assessments for Resident #9. This failure could place residents at risk for delayed treatment, care, and services that could result in not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Findings include: Record review of Resident #9's face sheet revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include diabetes mellitus with hyperglycemia. Record review of Resident #9's quarterly MDS completed on 04/05/2022 revealed an active diagnoses of Diabetes mellitus checked in section I2900. Record review of Resident #9's facility provided care plan revealed it was last updated 12/21/2021. There were no other care plans completed at the time of review. The care plan did not reveal any diagnoses or treatment plans for Resident #9's diagnosis of diabetes. During an interview on 07/13/2022 at 7:53 PM with the DON, DON stated she was responsible for updating the care plans. DON stated care plans should have been updated/revised quarterly and when significant changes occurred. She verified the last care plan that had been completed for Resident #9 was dated 12/21/2021 and she was currently working on the new care plan. DON was asked how soon after an MDS was completed should a new care plan have been completed and the DON stated 10 days. DON confirmed the dates of MDS and Care Plans for Resident #9 had not been updated/revised within the timeframe. DON stated she was not employed at the facility when the care plan was not completed after the quarterly MDS assessment dated [DATE]. Record review of facility provided policy titled. Care Planning- Interdisciplinary Team revised September 2013, revealed the following: Policy Interpretation and Implementation 1. A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 7 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 0657 d. At least quarterly, in conjunction with the required quarterly MDS assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 8 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication cart reviewed for medication labeling. The only medication cart in the facility contained an insulin pen that did not contain a resident identifying label or open or discard date. This failure could place residents at risk for receiving the wrong insulin or receiving insulin that has expired. Finding include: Record review of Resident #9's face sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type II diabetes mellitus with hyperglycemia (high blood sugar). Record review of Resident #9's quarterly MDS, dated [DATE], revealed a BIMS was not able to be conducted due to the resident rarely or never being understood. The staff assessment for mental status revealed Resident #9 had a long-term and short-term memory problem, could not recall any information during the assessment and had moderately impaired cognitive skills for daily decision making. Section G titled, Functional Status revealed she required extensive one-person assistance with bed mobility and transferring, total one-person dependence with toilet use and personal hygiene. Section I titled Active Diagnoses revealed a diagnosis of diabetes mellitus. Record review of Resident #9's care plan, dated [DATE], revealed, in part, [Resident #9] is at risk for Hyper/Hypoglycemia (high or low blood sugar) R/T diagnosis of Diabetes Type 2. Record review of Resident #9's physicians orders, dated [DATE], revealed, in part, .Order Date [DATE] Type 2 diabetes mellitus with hyperglycemia .Levemir flex pen (insulin) 28 Units SQ QPM Dx Diabetes .Levemir flex pen 28u SQ QD at 0630 (6:30 AM). Record review of Resident #9's treatment record, revealed Levemir initialed by staff as being administered every day for [DATE], up to [DATE]. During an observation and interview on [DATE] at 8:45 AM, a Levemir flex pen 100 units/mL was observed in the only medication cart with no open date or resident identifying information. The Levemir flex pen contained a manufacturer expiration date of [DATE] only. LVN B stated this belonged to Resident #9, she was the only resident taking that type of insulin, and LVN B said she used the last of the previous Levemir flex pen on that cart the previous Sunday morning ([DATE]) so she knew the night nurse opened that particular pen Sunday night ([DATE]). LVN B stated staff were supposed to label the flex pen with the date it was opened, and she also thought they should have asked the pharmacy for a label containing the resident's name. LVN B stated if it was her who put the flex pen in the medication cart, she would have labeled it with an open date, but she knew when it was opened. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 9 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked how staff would know who the flex pen belonged to since there was not any resident identifying information on it, she stated Resident #9 was the only resident taking that medication. When asked what if they had an agency staff member who was working who was not familiar with the residents, how would they know when it was opened and LVN B stated they might not know when the Levemir flex pen was opened. LVN B stated she did think staff would know who it belonged to because Resident #9 was the only resident on a Levemir flex pen. LVN B stated not labeling or dating insulin pens could have resulted in giving a resident the wrong medication. During an interview on [DATE] at 11:20 AM, DON stated all resident medications should have had a label on it containing the resident's name and the medication administration instructions. She stated insulin pens needed to be labeled with an open date, they were only good for 28 days after they were taken out of the refrigerator and opened. DON stated she would have expected her staff to discard an unlabeled insulin pen found in the medication cart and reorder a new one. She stated not having appropriately labeled medication could have resulted in staff giving a resident the wrong medication or administering a medication past its expiration date. Record review of a facility provided policy titled Administering Medications, dated 2012, revealed, in part, .7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container .14. Insulin pens will be clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 10 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: Residents Affected - Many A. Ensure foods were stored under sanitary conditions. B. Ensure expired food was discarded. These failures could place residents who ate food served by the kitchen at risk for food-borne illnesses. Findings include: In an observation on 07/11/2022 at 11:18 AM the following issues in the dry storage were observed: 1. 1 unopened Enriched Wheat Sandwich Bread, Best by date 6/21/2022 2. 3 unopened packs of 12 Hot Dog Bun Enriched, Best by date 7/7/2022 3. 1 opened pack of 12 Hot Dog Bun Enriched containing 9 hot dog buns not labeled, Best by dated 7/7/2022 In an observation on 07/11/2022 at 11:22 AM the following issues in the freezer were observed: 1. 1 box Cubed Beef Steak Fritters- Box is opened, bag is open to air. 2. 1 Box Boneless Pork Chop Fritter Box opened, bag is unsealed 3. 5 eggos- not dated, not in box 4. 1 half full container of Rainbow Sherbet- not dated with discard date, no open date In an observation on 07/12/2022 at 08:23 AM the following issues in the dry storage were observed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 11 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 0812 1. Level of Harm - Minimal harm or potential for actual harm 1 unopened Enriched Wheat Sandwich Bread, Best by date 6/21/2022 2. Residents Affected - Many 3 unopened packs of 12 Hot Dog Bun Enriched, Best by date 7/7/2022 3. 1 opened pack of 12 Hot Dog Bun Enriched containing 9 hot dog buns not labeled, best by date 7/7/2022 In an observation on 07/12/2022 at 08:26 AM the following issues in the freezer were observed: 1. 1 Box Boneless Pork Chop Fritter Box opened, bag is unsealed 2. 5 eggos- not dated, not in box 3. 1 half full container of Rainbow Sherbet- not dated with discard date, no open date In an observation on 07/12/2022 at 02:04 PM the following issues in the dry storage were observed: 1. 1 unopened Enriched Wheat Sandwich Bread, Best by date 6/21/2022 2. 3 unopened packs of 12 Hot Dog Bun Enriched, Best by date 7/7/2022 3. 1 opened pack of 12 Hot Dog Bun Enriched containing 9 hot dog buns not labeled, Best by date 7/7/2022 In an observation on 07/12/2022 at 02:06 PM the following issues in the freezer were observed: 1. 1 half full container of Rainbow Sherbet- not dated with discard date, no open date During an interview with Dietary Manager on 7/12/2022 at 2:12 PM, she stated the 12 Hot Dog Bun (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 12 of 13 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 676370 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmonee House 1400 Main St Amherst, TX 79312 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many best by date was 7/7/2022. She stated the Enriched Wheat Sandwich Bread best by date is 6/21/2022. The DM also stated today's date is 7/12/2022. The DM stated she just recently bought the Enriched Wheat Sandwich Bread two days ago and didn't realize it was past the best by date. The Dietary Manager removed the Enriched Wheat Sandwich Bread as well as the 4 packs of hot dog Buns and stated they needed to be discarded. The DM stated she did not see that they were past their best by date. When asked why it needed to be discarded, she stated The bread could have mold or bacteria. It could cause foodborne illness to residents. When this surveyor asked the DM why previously opened containers are required to have dates, she stated No one would know the date it needed to be discarded if it's not dated. She stated the food could hold bacteria and mold and cause foodborne illness in residents who consume it. DM stated all items needed to be sealed and dated to prevent foodborne illness in residents who consume it. Review of the facility Nutritional Services policy titled Food Receiving and Storage, revised December 2008, documents When food is delivered to the facility it will be inspected for safe transport and quality before being accepted . All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 13 of 13