Inspection·May 5, 2023

F 0880 Resident #4, COVID positive on 4/30/23 Level of Harm - Immediate jeopardy to resident health or safety Resident #5, COVID positive on 4/27/23 Residents Affected - Some Resident #7, COVID positive on 5/3/23 Resident #6, COVID positive on 5/3/23 Resident #8, COVID positive on 4/30/23 Record Review of an undated face sheet for Resident #1 revealed: admitted to the facility on [DATE] with the following diagnosis: Dementia, Type 2 diabetes, Osteoarthritis, Unspecified psychosis, Delirium Record Review of an undated face sheet for Resident #2 revealed: admitted to the facility on [DATE] with the following diagnosis of malignant neoplasm of bronchus and lung, Hypertensive heart disease, Type 2 diabetes, Hyperlipidemia Record Review of an undated face sheet for Resident #3 revealed: admitted to the facility on [DATE] with the following diagnosis: major depressive disorder, upspecified dementia, acute pain Record Review of an undated face sheet for Resident #4 revealed: admitted to the facility on [DATE] with the following diagnosis autoimmune thyroiditis, Hyperlipidemia, Depression, Hypertensive heart disease, Rheumatoid arthritis, Heart failure, Atrial fibrillation, Hypothyroidism, Major depressive disorder. Record Review of an undated face sheet for Resident #5 revealed: admitted to the facility on [DATE] with the following diagnosis Hyperlipidemia, Gastro-esophageal reflux; Acquired absence of right leg; Type 2 diabetes; Hypertensive heart disease; Chronic atrial fibrillation Record Review of an undated face sheet for Resident #6 revealed: admitted to the facility on [DATE] with the following diagnosis: essential hypertension; Restlessness and agitation; Cellulitis of lower left limb; Depression; anxiety; Psoriasis; Psychotic disorder Record Review of Resident #7's face sheet was unavailable for review. Record Review of an undated face sheet for Resident #8's revealed: admitted to the facility on [DATE] with the following diagnosis Hyperlipidemia; Atrial fibrillation; Chronic obstructive pulmonary disease; Type 2 diabetes; Hypertension; Nontraumatic intracerebral hemorrhage in brain stem. Above currently positive and quarantined for COVID 3 residents who were exposed to positive roommates, moved to different rooms and not in isolation. (Resident #9, Resident #10, Resident #11) Record Review of an undated face sheet for Resident #9 revealed: admitted to the facility on [DATE] (exposed to Resident #3) with the following diagnoses: chronic pain, primary hypertension, atrial fibrillation, Hyperlipidemia, Constipation, Cough (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 2 of 9 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 05/05/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record Review of an undated face sheet for Resident #10 revealed: admitted to the facility on [DATE] (exposed to Resident #4) with the following diagnoses: Hypertensive heart disease with heart failure; Anxiety disorder; Chronic kidney disease; Dependence on supplemental oxygen; Hypothyroidism; Acute and Chronic respiratory failure with hypoxia. Record Review of an undated face sheet for Resident #11 revealed: admitted to the facility on [DATE] (exposed to Resident #5) with the following diagnoses: Nonrheumatic aortic stenosis; Hypertensive, Unspecified Dementia; Hyperlipidemia, Major depressive disorder; Generalized edema, Restlessness and agitation. Record Review of an undated face sheet for Resident #12 revealed: admitted to the facility on [DATE] with the following diagnoses: Multiple sclerosis; chronic pain; seizures; Dysphagia; Gastro-esophageal reflux disease. During an observation on 5/4/23 at 9:10 a.m. upon arrival to facility, posting on door dated 01/04/23 stated, Effective immediately. Due to the weekly update of COVID19 cases, the transmission levels are high, and face masks must be worn until further notice. Thank you for understanding and your commitment in helping to keep our residents safe. During an observation on 5/4/23 at 9:11 a.m., upon entrance into the facility, sign in clipboard on entrance table and empty facemask box. During an interview on 5/4/23 at 9:15 a.m. with the ADON, stated that there were 8 residents who are positive for COVID in the building and staff are required to wear surgical masks unless they enter a positive resident room and then they are required to wear an N-95 mask. The ADON stated she was not aware that there were no masks available at the entrance table. The ADON stated that there is a posting on the facility door notifying of the county transmission rate but that it is from January 2023 and has not been updated. The ADON stated she did not know who was responsible for changing the door positing but believed it was the Administrator because the Administrator is the Infection Control Preventionist. The ADON stated visitors are not notified of the COVID outbreak when they enter the building and there is nothing posted to inform them. During an observation on 5/4/23 at approximately 10:00 a.m., of the 8 positive resident rooms, only 1 out of 8 positive resident rooms (Resident #5) had contact precautions and PPE usage notifications on the door. During an observation on 5/4/23 at approximately 10 a.m., of the 8 positive resident rooms, only 1 out of 8 rooms (Resident #8) had hand sanitizer on the PPE cart for staff to disinfect their hands before or after contact with the positive resident. During an observation on 5/4/23 at 10:10 a.m., Resident #9 (exposed roommate of Resident #3) was observed in wheelchair in living room with Resident #12 (non-exposed). During an observation on 5/4/23 at 10:15 a.m. Resident #10 (exposed roommate or Resident #4) was in sitting in hallway. During an Interview and observation on 5/4/23 at 11:10 a.m. with an LVN A, she stated she had no idea if there was COVID in the facility until she arrived to her shift and entered the nurse station. LVN A stated that after entrance into the facility she would have to walk past residents in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 3 of 9 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 05/05/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some common areas before entering the nurse station. LVN A stated that only resident representatives were notified of COVID in the facility and any other visitors or family that would enter the facility would not be informed that there was COVID. LVN A stated that only when she would see a visitor without a mask, would she then inform them that there is COVID. LVN A stated that there was only one mask at the front entrance when she arrived this morning and PPE is locked up near the business office and staff have no access to it. LVN A stated that when the HHSC Investigator arrived in the resident halls, there were no postings notifying staff or visitors that there were positive COVID residents in the rooms except for Resident #8's room. LVN A stated that there were no face shields available that morning, and not all PPE carts were stocked. During an observation on 5/4/23 at 11:37 a.m. of the facility's dining room, revealed exposed roommates of positive residents, Resident #9, Resident #10, and Resident #11 were sitting with unexposed residents waiting on lunch service. During an interview on 5/4/23 at 11:45 a.m. with CNA B; stated that Residents #9, #10, #11, who had positive COVID roommates were able to freely walk around the facility and eat with residents in the dining hall. The CNA B stated there were no extra precautions for infection control with the residents who were exposed but tested negative for COVID. CNA B stated that they were not properly washing or disinfecting their hands, there were no postings on positive resident doors until after the Investigator arrived and visitors would not know there was COVID in a room prior to this morning because there were no postings on the door and no PPE carts outside of each positive resident's room. CNA B stated that Resident #9 is completely dependent on staff for all care areas, and someone would have put her in the living room area. CNA B stated that Resident #12 is also completely dependent on staff for all care areas, and someone would have put her in the living room area. CNA B stated that Resident #9 was exposed to COVID to by her roommate Resident #3. CNA B stated that Resident #12 has her own room and has not been exposed to COVID. CNA B stated that because Resident #12 was put in the living room area with Resident #9, Resident #12 has now been exposed to a resident who had a positive roommate. CNA B stated that they are not keeping exposed residents in isolation or away from other residents. CNA B stated that when she arrived to work that day there were only 2 surgical masks left in the box at the facility's entrance. CNA B stated she does not know if there is COVID in the building until she walks through the building to the nurses station. CNA B stated that PPE supplies are locked up in a room and staff who care for residents do not have access to that room. CNA B stated she is not sure who the Infection Preventionist is at the facility. CNA B stated that if she were an agency staff member or a visitor she would not know if there was COVID in the building nor would she know what rooms COVID had because the rooms were not marked until after the investigator walked through. CNA B stated that we are not containing COVID, we are spreading it because most rooms did not have any signs or PPE carts outside of the rooms. During an interview with the ADM on 5/4/23 at 12:33 p.m.; stated that she was in charge of infection control but was unaware that 3 residents tested positive on 5/3/23 for COVID. The ADM stated she was not sure who tested the residents, and she should have been notified. The ADM stated that she was not aware that postings were not on positive resident doors and that it is policy for there to be postings. The ADM stated that staff are to wear full PPE including N-95 masks, gowns, gloves, and face shields/goggles when entering a COVID room. The ADM stated she was unaware that staff did not have access to the PPE supply and that they did not have face shields. The ADM stated they allowed exposed residents to roam the building. The ADM stated everyone in the building is exposed to COVID and it is a small facility. The ADM stated that she cannot guarantee that positive residents will not leave their rooms and roam the building. The ADM stated that that everyone is exposed to COVID, and they are not doing droplet precautions on exposed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 4 of 9 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 05/05/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents. The ADM stated she thought it was the ADONs job to put postings on the door. The ADM stated she did not know that staff were not notified of COVID positive staff/residents until they went back to the unit and had the shift change meeting. During an observation on 5/5/23 at approximately 12:36 p.m. of CNA D, exiting Resident #5's room with wearing an N-95 mask that was modified to fit like a surgical mask and walked down the hall towards the dining room area. During an interview and observation on 5/5/23 at 12:39 p.m. with CNA C; observed in Resident 11's room wearing an N-95 mask that was modified to fit like a surgical mask. CNA C stated she cut the N-95 mask loops and tied them to fit behind her ears instead of behind her head. CNA C stated that no one told her she could modify her mask. CNA C stated she had to wear a N-95 mask due to COVID in the building and modified it so it was more comfortable to wear. CNA C stated that she watched the in-service CDC videos on how to wear PPE and hand washing. During an interview and observation on 5/5/23 at 12:42 p.m. with CNA D; observed in the hallway towards Resident #11's room. CNA D was observed with a modified N-95 mask cut to fit like a surgical mask. CNA D stated that the N-95 mask was too tight and she cut the straps and tied them to loop behind her ears. CNA D stated that she was not trained to cut the N-95 mask and was not instructed to cut the N-95 mask to fit comfortably. CNA D stated that she had been in COVID positive resident rooms with a modified N-95 mask on. CNA D stated that she received CDC training on how to properly wear PPE and to wash her hands. CNA D was observed delivering a meal tray to Resident #11 and did not disinfect her hands after exiting Resident #11's room. CNA D was observed walking back to the dining room, did not disinfect her hands, and picked up another resident tray. During an interview and observation on 5/5/23 at 12:46 p.m. with the facility cook; observed wearing a modified N-95 mask that was cut and tied to fit like a surgical mask behind her ears. The [NAME] stated that she modified the mask because it was too tight and stated that the N-95 mask is designed to fit tight and looped around her head because it probably protects us from COVID. The [NAME] stated she was provided CDC training on how to properly wear PPE and proper hand washing. The [NAME] stated that after she watched the video, she should have changed her N-95 mask to a non-modified one. During an interview and observation on 5/5/23 at 12:49 p.m. with the Housekeeper in the resident hall cleaning; observed wearing a N-95 mask that was modified to fit like a surgical mask. The Housekeeper stated that she cut the mask loops and tied them to fit behind her ears because it is too tight and gives her headaches. The Housekeeper stated she had not been trained on how to properly wear the N-95 mask. During an observation on 5/5/23 at 12:55 p.m. of the Housekeeper, observed wearing modified N-95 mask. During an interview on 5/5/23 at 1:04 p.m.; with the ADM; The ADM stated she did not know that staff had modified their N-95 masks to fit like a surgical mask. The ADM stated she will address with the staff. The ADM was advised that the IJ will not be lifted until the facility had addressed the issues and corrections. During an interview on 5/5/23 at 1:15 p.m. with the ADON; stated that staff are not permitted to modify their N-95 masks. The ADON stated that there is no excuse for staff to modify their masks and by doing so, it is not providing them protection from COVID and could expose residents to COVID. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 5 of 9 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 05/05/2023 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 0880 ADON stated that COVID had been around for 3 years, and staff should know how to properly wear N-95 masks and have been in-serviced and trained on it. Level of Harm - Immediate jeopardy to resident health or safety Record Review of facility policies for infection control: Residents Affected - Some Review of the facility policy, Equipment and Supplies used during Isolation dated: 2001 Med Pass, revised September 2017; revealed: -The Infection Preventionist oversees the availability and inventory of prevention and control supplies. Review of the facility policy, Isolation-Categories of Transmission-Based Precautions, dated 2001 Med-Pass, revised October 2018; revealed: : -Appropriate notification is placed on the room entrance door and on the front of the chart so personnel and visitors are aware of the need for and type of precaution. When a resident is placed on transmission-based precautions, appropriate notification is placed ont eh room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution: -Signage informs staff of the type of CDC precautions, instructions for PPE use and/or instructions to see nurse before entering. -Facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by the less restrictive measures. Droplet Precautions: May be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking. -Residents on droplet precautions will be placed in a private room if available. Masks will be worn when entering the room. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. Resident transport: A mask will be placed on the resident during transport from his/her rooms. The resident will be encouraged to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets. Review of the facility policy, Isolation-Notices of Transmission-Based Precautions, dated 2001 Med-Pass, revised October 2018: -Notices will be used to alert personnel and visitors of transmission-based precautions: -When transmission-based precautions are implemented the Infection Preventionist (or designee) determine the appropriate notification to be placed on the room entrance door and chart so that personnel and visitors are aware for the need for and type of precaution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 6 of 9 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 05/05/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Airborne Precautions, Contact Precautions, Droplet Precautions: Place a notice on doorway instructing visitors to report to the nurses station before entering the room. Place a sign indicating (Aiborne, Contact or Droplet) precautions on the door to the resident room and resident chart. Review of the facility policy, Equipment and Supplies Used During Isolation, dated: 2001 Med Pass, revised October 2018, revealed: Residents Affected - Some Appropriate infection prevention and control equipment and supplies are obtained, stored and used in accordance with current guidelines and manufacturer instructions: The Infection Preventionist (or designee) oversees the availability and inventory of infection prevention and control supplies. Review of the facility provided policy, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 Pandemic, updated 9/27/2022; -Patient Placement: Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room; door should be kept closed (if safe to do so). Limit transport and movement of the patient outside of the room to medically essential purposes. On 5/4/23 at 3:18 p.m., The Administrator was notified that an Immediate Jeopardy had been identified, IJ template provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as followed) was accepted 5/5//23 at 1:59 p.m. What potential deficiency is being addressed by this Action Plan?

F880 Infection Prevention and Control: It is alleged that the facility failed to implement and maintain an infection prevention and control program to provide a safe environment and help prevent the development and transmission of infectious diseases. Need for Immediate Action The IJ documentation provided by HHSC on May 4, 2023, states the relaxed mindset in contact precautions including wearing and supplying PPE, notifying visitors of facility positivity rate, not posting contact isolation and droplet precautions on resident rooms, and not providing hand sanitizer could potentially bring in infection to any already vulnerable population. This could possibly spread to other staff and residents within the facility, which ultimately could affect the health and well-being of all residents. Document the facility's actions taken to remove the immediacy in an IJ situation. Following notification by the surveyor of the lack of signage notifying staff and visitors of the existence of Covid in the building, the administrator put a sign on the door of the building, by the sign-in station and two signs on the facility doors which read: There is currently a CoVid-19 outbreak in the building. Masks required. Masks were placed at the sign-in desk for visitors to use. PPE and hand sanitizer was restocked in all isolation carts. Signs were placed on the doors of the isolated residents stating Droplet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 7 of 9 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 05/05/2023 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 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Precautions required. The residents who were exposed to the positive residents were placed on Contact Precautions. Exposed residents on Contact Precautions will be kept in their rooms away from other residents until cleared of the possibility of having Covid. In the future, all exposed residents will be moved to another room away from positive and negative residents until they have been cleared of the possibility of having Covid. All residents were tested on [DATE], and then two residents were tested again based on Doctor's orders on May 4, 2023. These two residents tested positive. The two new positives on May 4, 2023, were the only ones the Administrator was unaware of at the time of the entrance of the surveyor. Both the new positives were reported to NHSN per regulations. As of May 5, 2023, no new positive residents have been identified. Only 1 resident has any symptoms, which is a runny nose. All staff who are not on vacation or out with Covid were in-serviced on Hand Hygiene and Correct PPE Usage using videos from CDC (Clean Hands: Combat CoVid-19 and Use Personal Protection Equipment (PPE) Correctly for CoVid-19). Staff who are PRN, currently on vacation or out with Covid will be required to complete the training prior to coming into the facility to work. Staff were also in-serviced on who the Infection Preventionist is. Which residents were affected by this situation? All residents have the potential to be affected by the alleged deficient Infection Prevention standards. Who else is potentially affected? All residents, staff and visitors have the potential to be affected by this deficient practice. [facility] states the situation described above has been mitigated and is in substantial compliance as of May 5, 2023. Monitoring of the Plan of Removal included: During an observation of the facility entrance door on 5/5/23 at 12:00 p.m., notice of COVID posted on entrance door and mandate to wear masks. During an observation of the entrance table inside the facility door on 5/5/23 at 12:00 p.m.; N-95 masks were on the entrance table next to hand sanitizer and a sign in sheet for staff and visitors to report any COVID symptoms. During an interview on 5/5/23 at 12:10 p.m. with the ADM, stated that all resident rooms had postings notifying staff and visitors that PPE is required, and PPE carts have been placed and filled by resident rooms. The ADM stated that all residents who are positive or had been exposed are on quarantine. The ADM stated that the facility has trained the majority of the facility staff and will continue to train staff as they arrive for their shifts. The ADM stated that staff had been trained on N-95 masks, Droplet precautions, Contact Precautions, Infection Preventionist, PPE/Donning/Doffing, and watched a CDC video on COVID-19 and the ADON is verifying staff are watching the video and also verbally is instructing staff. During an observation on 5/5/23 at approximately 12:40 p.m. revealed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11 room doors had notices of contact precautions, PPE required and full PPE (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 8 of 9 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 05/05/2023 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 0880 carts outside doors. Level of Harm - Immediate jeopardy to resident health or safety During an interview and observation on 5/5/23 at 3:15 p.m. with LVN A, CNA C, CNA D at the nurses station, all staff were observed wearing N-95 masks correctly. CNA C stated she was trained to wear her N-95 properly and to not modify the mask. CNA C stated that all staff are trying to redirect residents who have been exposed to COVID to stay in their rooms. CNA D stated that if she saw an exposed resident out of their room, she redirects them to their room. CNA D stated that there is plenty of PPE in the facility and all positive or isolated resident rooms have postings on the doors and full PPE carts outside the door. LVN A stated that all staff must wear N-95s in the facility and must wear full PPE in all positive resident rooms and exposed resident rooms. Residents Affected - Some During an observation on 5/5/23 at 3:30 p.m. in the facility's library, the ADON was in-servicing kitchen and housekeeping staff on proper handwashing, PPE, and isolation procedures. Record Review of the facility provided in-service sign in sheets provided on 5/5/23 revealed staff were trained on N-95 masks, Droplet precautions, Contact Precautions, Infection Preventionist, PPE/Donning/Doffing, and watched CDC COVID-19 Prevention Messages for Frontline Long Term Care Staff-Use Personal Protective Equipment(PPE) correctly for COVID-19 (https://www.youtube.com/watch?v=YYTATw9yav4) An Immediate Jeopardy (IJ) was identified on 5/04/23 at 1:45 PM and the IJ template was provided to the facility Administrator on 5/04/23 at 3:18 PM. While the immediate jeopardy was lifted on 5/5/23 at 3:34 PM the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676370 If continuation sheet Page 9 of 9