Harmony Care at Brookshire

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #2) reviewed for incontinent care. The facility failed to ensure CNA B properly cleaned Resident #2 during incontinent care on 06/17/2026. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents (Resident #2) and 1 of 2 staff (CNA B) reviewed for infection control. The facility failed to ensure CNA B washed or sanitized her hands and performed glove changes appropriately while providing incontinence care to Resident #2 on 06/17/26. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 (Resident #1 and Resident #2) out of 7 residents observed for resident rights. LVN B failed to sit at eye level when feeding Resident #1 their lunch in the dining room, LVN B stood while feeding Resident #1. CNA A failed to sit at eye level when feeding Resident #2 their lunch in the dining room. CNA A stood while feeding Resident #2. This failure could place residents at risk for choking and compromising their dignity and respect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food to be used later with a temperature in the danger zone was discarded which pan of mechanical soft sausage in the steamtable 131.1 degrees Fahrenheit2. The facility failed to ensure that food past the used by date were discarded which included a pan of cooked rice in the refrigerator use by date 2/7/26, a pan of mashed potato use by date 2-3-26, a pan of Salisbury steak use by date 1-7-26, a package of shredded cheddar cheese use by date 1-12-26, a package of deli meat turkey use by date 1-29-26,a package of shredded swiss cheese use by date 12-15-25.3. [...]

Inspectors wroteDuring a confidential group meeting, residents stated that staff had not knocked on their doors and announced themselves before entering their room. One of 10 confidential group residents stated that she had been in the middle of dressing when staff walked into her room. She stated that the staff had no regard in providing her with privacy and freedom of feeling exposed. During an interview on 02/12/2026 at 09:27 a.m. the Administrator (ADM) stated that he had been made aware that knocking on residents' doors before entering their rooms had been an issue. He stated that the staff received in-service training on customer service once a month which included - no expectations knock on resident's doors before entering a resident's room. He stated staff were to knock, wait and give the residents the ability to welcome the staff in, and then enter, and announce the goal of the visit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 1 of 10 confidential residents reviewed for personal privacy. The facility failed to ensure facility staff knocked on residents' doors prior to entering their rooms. This failure could allow residents' protected HIPAA information to be shared with individuals who did not have a need or right to know and could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. During a confidential group meeting, residents stated that staff had not knocked on their doors and announced themselves before entering their room. One of 10 confidential group residents stated that she had been in the middle of dressing when staff walked into her room. [...]

Inspectors wroteBased on interviews and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 10 of 10 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 10 confidential residents. These failures placed residents at risk for decline in quality of life, social and mental psychosocial wellbeing. During a confidential group interview on 02/11/2026 at 02:10 p.m., with 10 confidential residents, all residents stated that there were no weekend activities and nothing to do around the facility on those days. Four of the 10 residents stated it was boring, and it was nonsense that the facility could not provide them with activities on the weekends. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 14% based on 5 errors out of 34 opportunities, which involved 2 of 7 residents (Resident #35, and Resident #83) reviewed for medication errors. The facility failed to ensure MA P administered the correct dose of Vitamin B-12 (use to make and support healthy) to Resident #35 on 2/10/26. LVN G failed to administer Timolol Maleate (used to lower high fluid pressure inside the eye) Ophthalmic Solution 0.5 % eyedrops ophthalmic drops, on 2/11/25, initialed as given to Resident #83, when it was not given. LVN G failed to administer Brimonidine Tartrate (used to lower pressure of the eye) 0.2 % Solution eyedrops ophthalmic drops, on 2/11/25, initialed as given to Resident #83, when it was not given. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 5 of 28 residents ( Resident #96, Resident #2, Resident # 65, Resident #83 and Resident #32) and 3 of 3 staffs (CNA H, LVN S,LVN G ) reviewed for infection control. -The facility failed to ensure CNA H performed hand hygiene during incontinent care on Resident #32. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 3 residents (Residents #32) reviewed for incontinent care, in that: CNA H did not clean Resident #32's open labia during indwelling Foley Catheter incontinent care. During incontinent care for Resident#32 CNA used wet wipes to clean in-between the buttocks, cleaning the buttocks from the top of the buttockstoward the vaginal area. These failures could place residents at-risk for infection due to improper care practices. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #96) of 4 residents reviewed for enteral nutrition. The facility failed to properly label Resident #96's enteral feeding formula to identify what date, time and by which staff administered and hung the feeding. This failure could place residents who had gastrostomy tube at risk receiving expired fluids.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 6 residents (Residents #83) reviewed for significant medication errors. LVN G failed to administer a substantial amount of potassium CL via GT ( medication used for essential mineral and electrolyte that keep the heart beating regularly, muscles contracting and nerves communicating) to Resident # 83 after dissolving potassium CL in water in the medication cup, on 2/11/26 This failure could place residents at risk of abnormal heart rhythms, and potential hospitalizationRecord review of Resident #83's face sheet dated 2/11/26 revealed a [AGE] year-old female resident that was admitted to the facility on [DATE] and was readmitted [DATE]. Resident #83 had diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (secured unit). -The secured unit nurse medication cart A contained opened undated medication. These failures placed residents at risk of receiving expired medication and improperly stored medications which could result in delayed healing. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure effective administration to maintain the highest practicable well-being of each resident. The facility operated without an administrator from 08/20/25 to 09/13/25, in the 1 of 1 facility reviewed for administration. Record review of personnel records revealed the Former Administrator was terminated on 08/19/2025, there was no record of a licensed interim or permanent replacement appointed from the period of 08/20/2025 - 09/13/2025. During an interview on 09/13/2025 @ 10:30am with the nurse supervisor, she stated that the facility had not had a facility administrator, since 08/2025. She stated that DON, who was not a state-licensed nursing home administrator, was informally made responsible for the Administrator's tasks. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that all staff were trained in the procedures for reporting abuse, neglect, exploitation, or misappropriation of resident property for 6 of 6 facility employees reviewed for training. The facility failed to provide training on the identity of the Abuse Coordinator and the procedures for reporting abuse. This deficient practice has the potential to affect all residents by placing them at risk for unrecognized or unreported abuse due to staff being unaware of who to report to and how to initiate the facility's abuse reporting process. Observation 09/13/2025 @ 2:40pm, during the onsite visit, revealed the facility had not update the signage and posting of the facility's Abuse Coordinator. The posting reflected the Former Abuse Coordinator, who was terminated on 08/19/2025, contact information. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 out of 2 residents (Resident #3) reviewed for environment. - The facility failed to ensure Resident #3's room was clean and a homelike environment. There was sheetrock debris and dust on the resident's floor and on her windowsill. - The facility failed to relocate Resident #3 to another room while sheetrock repair work was actively being performed in her room. This deficient practice could place residents at risk of environmental hazards such as airborne dust, construction debris, noise and physical risk which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 5 hallways, (Hall 100 and Hall 400) and the conference room. The facility had live gnats in areas of the facility including Halls 100 and 400, and in the conference room. This failure could place residents at risk for resident health, safety and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 1 of 7 residents (Resident # 1) reviewed for pharmacy services. The facility failed to ensure that Resident # 1 received her prescribed medication, Midodrine, according to physician's orders on 2/9/2025. Resident #1 was administered 10 tablets of Midodrine (medicationused to treat low blood pressure) instead of the ordered one tablet. Resident # 1's blood pressure was 189/96 before being transported to the hospital for an overdose of Midodrine An Immediate Jeopardy (IJ) was identified on 2/13/2025. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 (Resident #29) residents reviewed for pain management. C.NA A failed to stop performing incontinent care while Resident #29 was in pain. C.NA A failed to notify the LVN B of Resident #29's pain in a timely manner after incontinent care in AM. This failure could place resident at risk for increased pain causing undo suffering.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 of 5 halls (100-hall, 400-hall and 500-hall). - The facility failed to address discoloration on ceiling tiles throughout the facility. - The facility failed to address missing floor and wall tiles. - The facility failed to address exposed sheetrock in the halls and resident rooms. - The facility failed to address chipped wall paint in the halls and resident rooms. - The facility failed to address damaged exit door handles. - The facility failed to address damaged door frame and door handle to storage room. - The facility failed to address damaged handrails. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen #1) reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/prepared and discarded after 72 Hours (3 days) per facility policy in Kitchen #1 2. Discolored and debris covered kitchen ceiling vents 3. Discolored shelves in refrigerators This failure could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen on 12/02/24 at 8:04 AM revealed the following. 1. A large rectangular pan with gelatin and fruit in the refrigerator/cooler uncovered and undated/labeled. 2. A square pan of pureed carrots that were not dated. 3. [...]

Inspectors wroteBased on interviews and record review, the facility failed to electronically submit to CMS a complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2024 for the first quarter March 1, 2024 to November 30, 2024). The facility failed to submit PBJ staffing information to CMS for the 4th quarter of the fiscal year 2024. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals used in the facility were accurately acquired, received, dispensed, and administered in accordance with currently accepted professional standards and failed to remove medications for disposition from current medication supply that were discontinued or the residents had been discharged for 3 of 6 medication carts (100 and 200 hall MA medication cart C, 500 hall nurse cart A, and 400 hall nurse cart B) reviewed. 1. The facility failed to ensure 100 and 200 hall MA medication cart C did not contain discharged residents' medications. 2. The facility failed to ensure 500 hall nurse medication cart A did not have expired medications, discharged resident medication, and discontinued medications. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 6 medication carts (500 hall nurse cart A and 400 hall nurse cart B), and failed to ensure all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (400 hall nurse medication B) reviewed for medication storage -The 500-hall nurse medication cart A contained opened undated medication and medication not stored in the original packaging delivered from the pharmacy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 2 (Resident #168, and Resident 29) of 6 residents reviewed for personal privacy. The facility failed to ensure LVN A locked the computer screen, displaying the name of Resident #168's name and medications, while LVN A was in resident's room administering finger stick and insulin. -The facility failed to provide Resident #29 privacy when providing incontinent care. These failures could place residents' protected HIPAA information at risk of being shared place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to accurately assess each resident's status for 1 of 5 Residents (Resident #7) reviewed for assessment accuracy in that: Resident #7 MDS and care plan were in accurate in that was indentified as being on anti-coagulants/antiplatelets when she was not. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #22 and Resident #65) reviewed for care plans. The facility failed to ensure Resident #22's comprehensive care plan addressed hospice. The facility failed to ensure Resident #65's comprehensive care plan addressed residing on the memory care unit. This deficient practice could affect residents by contributing to inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 6 residents (Resident #55 and Resident #28) reviewed for ADLs. The facility failed to ensure Resident #55, and Resident #28 was provided personal grooming(shaving) by facility staff. This failure could place residents at risk for discomfort, and dignity issues.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who was incontinent of bladder and bowel received appropriate treatment and services for 1 of 10 residents (Residents #29) reviewed for incontinent care, in that: CNA A did not clean Resident #29's groin, buttocks, or open labia to clean during incontinent care. CNA A used cleaning cloth wipe as the resident had bowel movement, and CNA A put the new brief under the resident's buttock without changing gloves, but the resident's buttock had residual of stool. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 9 residents (Residents #39) reviewed for significant medication errors. - RN C failed to administer medications as ordered to Resident # 39 by attempting to administer crushed potassium CL micro 20meq ER, which had the instruction, do not crush as ordered. This failure could place residents at risk of abnormal heart rhythms, and potential hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Staff (CNA A) reviewed for infection control. - The facility failed to ensure CNA A followed proper hand hygiene during incontinent care. These deficient practices could affect residents and place them at risk for infection, and reinfection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, leading to potential entrapment hazards for 1 (Resident #3) of 6 residents reviewed for safety in rooms. The facility failed to conduct regular inspections of resident bed frames and mattresses to identify risks and problems. Resident #3's bed had a significant gap between the mattress and bedframe. These failures could place residents at risk of injury resultant from equipment malfunction, entrapment, or falls.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public on three of five halls observed (hall 100, 400 & 500). Floors on Secured unit (hall 100) were dirty and stained. Resident bathrooms on halls 100 were unkept, unclean, had strong urine odor and unsanitary. Window blinds on halls 100, 500 were bent and torn and Hall 400 vertical blinds had missing slats. Windows on hall 100 has an accumulation of spider webs and green stuff on the outside. The toilet bowls on hall 100 had brown and black stains in them. The tiles in rooms on 100 hall was broken, based boards not affixed to the wall, broken sheet racks and peeling paint on the wall. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #3) of four residents reviewed for accommodation of needs. 1. Resident #3 was taken in the personal vehicle of Driver A to a dialysis appointment. Her wheelchair could not be accommodated, and she was asked to use her walker for mobility. 2. Resident #3 expressed being tired after dialysis and was left to wheel herself without assistance back to her room. This failure could decrease the resident's quality of life, increase anxiety, and put other residents at risk for not having their needs and preferences met.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for two (Resident #1 and Resident #2) of ten residents reviewed for ADL care. 1. Resident #1 had not had a shower since 05/11/24. 2. Resident #2 did not receive his scheduled shower on 05/28/24. These failures could place residents at risk for skin break downs, odor, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received food that accommodates resident preferences for one (Resident #4) of 3 residents reviewed for food preferences. 1. Resident #4 required total assistance during feedings and was served cold food during mealtimes. This failure could place resident who require assistance from staff during mealtimes at risk of not enjoying meals that meet their preferences. Findings Included: Record review of Resident #4's face sheet revealed an eighty-one-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were hemiplegia (total paralysis) and hemiparesis (partial paralysis) following cerebral infarction affecting left non dominant side, dysphagia (difficulty swallowing), encounter for attention to gastronomy (attention to how food is prepared), and cerebral infarction (stroke). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet resident's medical, nursing, mental, and psychosocial needs for one (Resident #2) of 8 residents reviewed for care plans. The facility failed to follow the physician orders for Resident #2 in relation to tube feeding. This failure could place 8 residents who receive tube feeding services at risk for not having their needs identified and addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as is possible for one (Resident #1) of six residents reviewed for transfers. CNA A failed to lock Resident #1's wheelchair during a transfer. This failure could place residents who require assistance during transfers at risk for falls and injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist with residents who were unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Resident #1 and Resident #2) reviewed for ADL's. -Resident #1 fingernails were observed with black debris underneath the nails. -Resident #2 was observed with a moderate amount of facial hair growing on her chin. These failures could place residents at risk for low self-esteem and decrease in dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 5 residents (Resident #1) reviewed for infection. -Resident #1s bedpan was laying on the floor in room over in a corner with no name on bedpan nor was the bedpan bagged. This failure placed resident at risk for unwanted infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 8 residents (Resident #164) reviewed for respect and dignity. -The facility failed to provide Resident #164 privacy when providing incontinent care. This failure could place residents at risk of embarrassment and lower self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 2 resident (Resident #40) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #40's Foley catheter was secured as ordered by the physician. 2. The facility failed to ensure Resident #40 heels were off loaded as ordered by the physician . These failures could place residents at risk of not receiving needed care and treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of lesser intensity as required in the resident's comprehensive plan of care for 1 of 8 residents (Resident #164) reviewed for specialized rehabilitative services. -The facility failed to ensure Resident #164 received her hand device (cone) to her right contracted hand to prevent further contracture. This failure could place residents at risk for further contractures , skin breakdown, and a decrease in physical capabilities.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to extent possible for 1 of 8 residents (Resident #164) reviewed for bowel and bladder incontinence. The facility did not provide timely, thorough, or proper incontinent care for Resident #164 to prevent UTI's. This failure could place residents at risk for skin breakdown, urinary tract infections, sepsis, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 8 residents (Resident #164) reviewed for infection control. 1. The facility failed to ensure CNA ZZ did not touch Resident #164 personal items with soiled gloves after incontinent care was performed. 2. The facility failed to ensure CNA ZZ and CNA TT washed or sanitized their hands after performing incontinent prior to leaving Resident #164's room. These failures could place residents at risk for cross contamination, spread of infections, and decrease in quality of life.